Which sentences contribute to a sense of hope in this excerpt from "The Story of an Hour" by Kate Chopin?She wept at once, with sudden, wild...

When Louise Mallard goes to her room right after she learns her husband died in a train accident, she locks the door and goes to sit in front of an "open window [in] a comfortable, roomy armchair."  The connotations of words like open, comfortable, and roomyare all very positive, and thus they begin to contribute to the hopeful mood.  It seems easier to imagine that a woman, having just learned of her...

When Louise Mallard goes to her room right after she learns her husband died in a train accident, she locks the door and goes to sit in front of an "open window [in] a comfortable, roomy armchair."  The connotations of words like open, comfortable, and roomy are all very positive, and thus they begin to contribute to the hopeful mood.  It seems easier to imagine that a woman, having just learned of her husband's death, might be unable to find any place comfortable or even feel emotionally equipped to look out at the wide world.  When we are terribly sad, we often hole up in a dark place and cry or sleep or both.  However, Louise does the exact opposite; she goes to her open window where she can experience the world outside, instead of dwelling in the world inside herself.

Further, the types of things Louise notices when she looks outside have even more positive connotations, and help to establish that sadness is not her overwhelming emotion;  in fact, she now feels hope.

She could see in the open square before her house the tops of trees that were all aquiver with the new spring life. The delicious breath of rain was in the air. In the street below a peddler was crying his wares. The notes of a distant song which someone was singing reached her faintly, and countless sparrows were twittering in the eaves.

Again Chopin uses the word open as if to signify the new possibilities of Louise's life, her increased options and freedom.  Moreover, it is spring, the season typically associated with rebirth; it is a hopeful season, after the chill death of winter, that heralds new life all around.  The trees are aquiver, the smell of coming rain is delicious, the trees and streets are full of life and sounds that are all completely positive and joy-giving and hopeful.  Water, like spring, also frequently connotes a new life or rebirth as well.  In addition, Louise hears music made by both people and birds, and the singing sparrows -- like her new possibilities -- are so numerous that they seem countless to her.  All of these descriptions work to establish not a sad or depressed mood but, rather, a hopeful, joyful one.  

How long did the police search for the murder weapon?

I scoured through this story in an attempt to find an exact amount of time that the police spent searching for the murder weapon.  There is no stated amount of time that the police spent looking for the murder weapon.  I can put forth a fairly accurate guess though.  

The story says that Mary Maloney was waiting for Patrick to get home.  She looked at the clock and it said 4:50.  

When the clock said ten minutes to five, she began to listen, and a few moments later, punctually as always, she heard the tires on the gravel outside, and the car door slamming, the footsteps passing the window, the key turning in the lock. She laid aside her sewing, stood up, and went forward to kiss him as he came in.

For the sake of simplicity, let's round the time off.  Patrick came home at 5 in the evening.  He comes in the door.  Sits down.  Finishes his first drink really quickly.  Gets a second drink.  Then he begins telling Mary that he is leaving her, which didn't take long. 

And he told her. It didn’t take long, four or five minutes at most, and she say very still through it all, watching him with a kind of dazed horror as he went further and further away from her with each word.

I figure that it is probably 5:15 at the latest.  Mary operates in a daze for a bit until Patrick tells her he is going out again.  Then she clubs him over the head with the leg of lamb and kills him.  After that, Mary cleans herself up, rehearses her grocery store exchange with Sam, and leaves for the grocery store.  The text tells readers that it was just before 6 o'clock at this point.  

It wasn’t six o’clock yet and the lights were still on in the grocery shop.

Mary gets the groceries that she needs and heads home.  She is "shocked" to see her husband dead on the floor, so she calls the police. The police "came very quickly."  I figure 6:30 at the earliest.  From that point forward, I have to assume that the police began to look for potential murder weapons.  

At 9 that night, Mary offered to feed the remaining officers.  They all sat down to eat the murderous leg of lamb.  It's possible that the police kept searching after their meal, but the story ends.  By my calculations, the police searched for the murder weapon for about two and a half hours.   

What is self-medication? |

Indications and Procedures

Every day, millions of people take medicinal drugs. Usually this is because they are experiencing symptoms, want to experience a particular feeling, or want to prevent a problem from developing and have information leading them to believe that the drug is the answer. For some, this occurs under the direction of a physician through the use of prescription medications. For others, this occurs through self-medication as a form of treatment. Most popularly, there are those who, through advertisements or personal experience, have learned that certain over-the-counter medications
or popular legal drugs (such as cigarettes or alcohol) can be used to alleviate symptoms, provide palliative care, or cause certain symptoms or feelings. Others, via self-knowledge or guidance from alternative medicine specialists, will use teas, herbal remedies, and vitamins to achieve these same goals. Similarly, others may use illicit drugs to self-medicate in order to adjust their
mood, physical feelings, or other abilities. For these individuals, it may be that they have didactic knowledge about drug properties or have learned about drug effects through their experience with drugs. Relatedly, even those receiving prescribed drugs may abuse those drugs by using them in ways unapproved by their doctor. This may be due to judgments that they need more or less of the drug or need to mix it with something else to get the desired effect(s). Together, access to drugs, knowledge of dosages and drug effects, and having a culture that encourages use of medicinal remedies and drugs all contribute to self-medication.

Uses and Complications

Drug interactions can be a danger of self-medication. When individuals mix different medicines, legal drugs, or illegal drugs, there is a risk that they may cause themselves harm. Some drug interactions can cause medicinal drugs to be less effective for treating the condition needing attention. Others can lead to substantial discomfort or more serious conditions such as seizures or death. Similar problems can come from mixing certain medicinal substances and herbal remedies with each other or with certain foods. As such, anyone using self-medication as a treatment strategy should learn as much as possible about the drug(s) they are taking. Persons who self-medicate in addition to taking prescription drugs should inform their physicians of the nonprescription drugs they are taking.

Another problem of self-medication as a style of treatment is that unsupervised medical problems can often worsen without proper care. Using alcohol, cigarettes, or marijuana to alleviate conditions such as anxiety or depression may provide relief in the short term, but in the long term such use may worsen the mood problems and lead to substance abuse or dependence. Similarly, taking an antacid or laxative can be helpful for minor gastrointestinal problems, but prolonged use of such drugs can result in dangerous physical conditions not getting much-needed medical attention. Therefore, the limits of self-medication as a strategy must be known.

Perspective and Prospects

More than 30 percent of individuals living in the United States use an over-the-counter drug in any two-day period. It is estimated that 54 percent of three-year-olds receive over-the-counter drugs in any thirty-day period. Elderly adults use 25 percent of all over-the-counter drugs. Research also shows that 70 to 95 percent of all illnesses are managed without physician assistance. Additionally, over-the-counter drugs, herbal remedies, legal drugs, and illicit drugs constitute multibillion-dollar industries. Given these trends, self-medication as a treatment strategy is likely to continue. Increases can be expected as well because it is becoming easier to gain knowledge about how to use drugs safely. Furthermore, the practice of self-medication has the potential to decrease health care costs substantially by reducing the need for health care services, conserving valuable physician time.

The presence of self-medication as a positive force, however, must be balanced against problems such as a lack of compliance with medication regimens and the use of illicit and legal drugs to manage untreated mental and physical illnesses. When people do not take medicines as directed or fail to get proper medical treatment, problems can worsen. Work in the health care field therefore will need to address the longer-term problems that can develop as a result of these types of practices. Such investments may require increased time from service providers for purposes such as assessment and diagnosis, so as to uncover the hidden illnesses causing individuals to look for medicinal help in the first place. Additionally, barriers to treatment will have to be brought down so as to allow individuals who need medical and other health care to get the help they deserve.

Bibliography

Chamberlain, Logan V. What the Labels Won’t Tell You: A Consumer’s Guide to Herbal Supplements. Loveland, Colo.: Interweave Press, 1998.

Gorman, Jack M. The Essential Guide to Psychiatric Drugs. 4th ed. New York: St. Martin’s Press, 2007.

Graedon, Joe, and Teresa Graedon. Dangerous Drug Interactions: How to Protect Yourself from Harmful Drug/Drug, Drug/Food, Drug/Vitamin Combinations. Rev. ed. New York: St. Martin’s Press, 1999.

Griffith, H. Winter. Complete Guide to Prescription and Nonprescription Drugs. Revised and updated by Stephen Moore. New York: Penguin Group, 2010.

Khantzian, Edward J., Mark J. Albanese. Understanding Addiction as Self Medication: Finding Hope Behind the Pain. Lanham, Maryland: Rowman & Littlefield, 2008.

Luciani, Joseph J. Self-Coaching: The Powerful Program to Beat Anxiety and Depression. 2nd ed. New York: Wiley, 2006.

Silverman, Harold M. The Pill Book. 13th ed. New York: Bantam Books, 2008.

Vandeputte, Charles. Alcohol, Medications, and Older Adults: A Guide for Families and Other Caregivers. St. Paul, Minn.: Johnson Institute, 1991.

Weil, Andrew. Natural Health, Natrual Medicine: The Complete Guide to Wellness and Self-Care for Optimum Health. New York: Mariner, 2004.

What are St. John's wort's therapeutic uses?

Overview

St. John’s wort is a common perennial herb of many branches and bright yellow
flowers that grows wild in much of the world. Its name derives from the herb’s
tendency to flower around the time of the feast of St. John. (“Wort” simply means
“plant” in Old English.) The species name perforatum derives from
the watermarking of translucent dots that can be seen when the leaf is held up to
light.

St. John’s wort has a long history of use in treating emotional disorders. During
the Middle Ages, St. John’s wort was popular for “casting out demons.” In the
nineteenth century, the herb was classified as a nervine, or a treatment for
so-called nervous disorders. When pharmaceutical antidepressants were invented, German researchers began to
look for similar properties in St. John’s wort.

Therapeutic Dosages

The typical dosage of St. John’s wort is 300 milligrams (mg) three times a day of an extract standardized to contain 0.3 percent hypericin. Some products are standardized to hyperforin content (usually 2 percent to 3 percent) instead of hypericin. These are usually taken at the same dosage. Two studies found benefits with a single daily dose of 900 mg.

Another form of St. John’s wort has shown effectiveness in double-blind studies. This form contains little hyperforin and is taken at a dose of 250 mg twice daily. There is some evidence that this form of St. John’s wort may be less likely than other forms to interact with medications.

Therapeutic Uses

In Germany, other parts of Europe, and the United States, St. John’s wort is now a
widely used treatment for depression. The evidence base for its
use approaches that of many modern prescription drugs at the time of their first
approval.

Most studies of St. John’s wort have evaluated individuals with major depression of mild to moderate intensity. This contradictory-sounding language indicates that the level of depression rises to greater severity than simply feeling “blue.” However, it is not as severe as the most severe forms of depression. Typical symptoms include depressed mood, lack of energy, sleep problems, anxiety, appetite disturbance, difficulty concentrating, and poor stress tolerance. Irritability can also be a sign of depression.

Taken as a whole, research suggests that St. John’s wort is more effective than placebo and approximately as effective as standard drugs. Furthermore, St. John’s wort appears to cause fewer side effects than many antidepressants. However, the herb does present one significant safety risk: It interacts harmfully with a great many standard medications.

St. John’s wort has also shown promise for treatment of severe major depression. St. John’s wort alone should never be relied on for the treatment of severe depression. Persons who are feeling suicidal or who are unable to cope with daily life or who are paralyzed by anxiety, incapable of getting out of bed, unable to sleep, or uninterested in eating should consult a physician or other health practitioner.

St. John’s wort has been tried in the treatment of many other conditions in which
prescription antidepressants are thought useful, such as attention deficit
disorder, anxiety, insomnia, menopausal symptoms, premenstrual syndrome (PMS),
seasonal affective disorder (SAD), and social phobia. However, there is no
convincing evidence that it offers any benefit for these conditions. One
substantial double-blind study did find St. John’s wort potentially helpful for
somatoform disorders (commonly called psychosomatic illnesses).

Standard antidepressants are also often used for diabetic neuropathy and other forms of neuropathy (nerve pain). However, a small double-blind, placebo-controlled trial failed to find St. John’s wort effective for this purpose. Another study failed to find St. John’s wort helpful for obsessive-compulsive disorder.

St. John’s wort contains, among other ingredients, the substances hypericin and
hyperforin. Early reports suggested that St. John’s wort or synthetic hypericin
might be useful against viruses such as HIV (human immunodeficiency virus), but
these have not panned out. However, there is some evidence that hyperforin may be
able to fight certain bacteria, including some that are resistant to
antibiotics. This evidence is far too preliminary for any
conclusions to be drawn regarding the effectiveness of St. John’s wort as an
antibiotic. Based on weak evidence that hypericin might have anti-inflammatory
properties, St. John’s wort cream has been tried as a treatment for eczema, with
some promising results.

One interesting double-blind study evaluated a combination therapy containing St.
John’s wort and black cohosh in 301 women with general menopausal symptoms
as well as depression. The results showed that use of the combination treatment
was significantly more effective than placebo for both problems.

In a small placebo-controlled trial, hypericin extract showed no benefit for burning mouth syndrome, a poorly understood condition in which a person experiences ongoing moderate to severe pain in the tongue or mouth, or both.

Scientific Evidence

Depression. Two main kinds of studies have examined the use of St. John’s wort for depression: those that compared St. John’s wort to placebo and others that compared it to prescription antidepressants. A 2008 detailed review of twenty-nine randomized, placebo-controlled trials found that St. John’s wort was consistently more effective than placebo and just as effective as standard antidepressants.

St. John’s wort versus placebo. Studies of St. John’s wort (and other antidepressants) use a set of questions called the Hamilton Depression Index (HAM-D). This scale rates the extent of depression, with higher numbers indicating more serious symptoms.

Double-blind,
placebo-controlled trials involving a total of more than
fifteen hundred participants with major depression of mild to moderate severity
have generally found that use of St. John’s wort can significantly reduce HAM-D
scores compared with placebo. In addition, continued treatment with St. Johns wort
over six months may be effective at preventing a relapse of moderate depression in
patients who recover from an initial acute episode. For example, in a six-week
trial, 375 persons with average seventeen-item HAM-D scores of about 22
(indicating major depression of moderate severity) were given either St. John’s
wort or placebo. Persons taking St. John’s wort showed significantly greater
improvement than those taking placebo.

Three double-blind, placebo-controlled trials evaluating individuals with a similar level of depression failed to find St. John’s wort more effective than placebo. However, three studies cannot overturn a body of positive research. It should be noted that 35 percent of double-blind studies involving pharmaceutical antidepressants have also failed to find the active agent significantly more effective than placebo. As if to illustrate this, in two of the three studies in which St. John’s wort failed to prove effective, a conventional drug (Zoloft in one case, Prozac in the other) also failed to prove effective. The reason for these negative outcomes is not that Zoloft or Prozac does not work. Rather, statistical effects can easily hide the benefits of a drug, especially in a condition such as depression, where there is as a high placebo effect and no really precise method of measuring symptoms. Thus, unless a whole series of studies find St. John’s wort ineffective, especially trials in which a comparison drug treatment does prove effective, St. John’s wort should still be regarded as probably effective for major depression of mild to moderate severity.

St. John’s wort versus medications. At least eight double-blind trials enrolling a total of more than twelve hundred people have compared St. John’s wort with fluoxetine (Prozac), citalopram (Celexa), paroxetine (Paxil), or sertraline (Zoloft). In all of these studies, the herb proved as effective as the drug and generally caused fewer side effects.

In the largest of these trials, a six-week study of 388 people with major depression of mild to moderate severity, St. John’s wort proved just as effective as the drug citalopram (Celexa) and more effective than placebo. Additionally, Celexa caused a significantly higher rate of side effects than St. John’s wort. There were also significantly more side effects in the placebo group than in the St. John’s wort group, presumably because treatment of depression reduces physical symptoms of psychological origin. St. John’s wort also has been compared with older antidepressants, with generally favorable results.

How does St. John’s wort work for depression? Like pharmaceutical
antidepressants, St. John’s wort is thought to raise levels of neurotransmitters in the brain, such as serotonin,
norepinephrine, and dopamine. The active ingredient of St. John’s wort is not
known. Extracts of St. John’s wort are most often standardized to the substance
hypericin, which has led to the widespread misconception that hypericin is the
active ingredient. However, there is no evidence that hypericin itself is an
antidepressant.

Another ingredient of St. John’s wort, hyperforin, has shown considerable promise as the most important ingredient. Hyperforin was first identified as a constituent of Hypericum perforatum in 1971 by Russian researchers, but it was incorrectly believed to be too unstable to play a major role in the herb’s action. However, subsequent evidence corrected this view. It now appears that standard St. John’s wort extract contains about 1 percent to 6 percent hyperforin. Evidence from animal and human studies suggests that it is the hyperforin in St. John’s wort that raises the levels of neurotransmitters. Nonetheless, there may be other active ingredients in St. John’s wort also at work. In fact, two double-blind trials using a form of St. John’s wort with low hyperforin content found it effective. More research is necessary to discover just how St. John’s wort acts against depression.

Polyneuropathy. A double-blind, placebo-controlled trial of fifty-four people with diabetic neuropathy or other forms of neuropathy (pain, numbness, or tingling caused by injury to nerves) did not find St. John’s wort effective for this purpose.

Safety Issues

St. John’s wort taken alone usually does not cause immediate side effects. In a study designed to look for side effects, 3,250 people took St. John’s wort for four weeks. Overall, about 2.4 percent reported problems. The most common complaints were mild stomach discomfort (0.6 percent); allergic reactions, primarily rash, (0.5 percent); tiredness (0.4 percent); and restlessness (0.3 percent). Another study followed 313 individuals treated with St. John’s wort for one year. The results showed a similarly low incidence of adverse effects.

In the extensive German experience with St. John’s wort as a treatment for depression, there have been no published reports of serious adverse consequences from taking the herb alone. Animal studies involving enormous doses of St. John’s wort extracts for twenty-six weeks have not shown any serious effects.

However, there are a number of potential safety risks with St. John’s wort that should be considered. These are outlined in the following sections.

Photosensitivity. Cows and sheep grazing on St. John’s wort have
sometimes developed severe and even fatal sensitivity to the sun. In one study,
highly sun-sensitive people were given twice the normal dose of the herb. The
results showed a mild but measurable increase in reaction to ultraviolet (UV)
radiation. Another trial found that a one-time dose of St.
John’s wort containing two or six times the normal daily dose did not cause an
increased tendency to burn, nor did seven days of treatment at the normal dose.
However, there is a case report of severe and unexpected burning in an individual
who used St. John’s wort and then received UV therapy for psoriasis. In addition,
two individuals using topical St. John’s wort experienced severe reactions to sun
exposure.

Persons who are especially sensitive to the sun should not exceed the recommended dose of St. John’s wort and should continue to take the usual precautions against burning. Individuals receiving UV treatment should not use St. John’s wort at all, and those who apply St. John’s wort to the skin should keep those parts of their bodies shielded from the sun.

In addition, combining St. John’s wort with other medications that cause increased
sun sensitivity, such as sulfa drugs and the anti-inflammatory
medication piroxicam (Feldene), may lead to problems. The medications omeprazole
(Prilosec) and lansoprazole (Prevacid) may also increase the tendency of St.
John’s wort to cause photosensitivity.

Finally, a report suggests that regular use of St. John’s wort might also increase the risk of sun-induced cataracts. Although this information is preliminary, it would be prudent for persons taking the herb on a long-term basis to wear sunglasses when outdoors.

Drug interactions. Herbal experts have warned for some time that
combining St. John’s wort with drugs in the Prozac family (SSRIs) might
raise serotonin too much and cause a number of serious problems. Recently, case
reports of such events have begun to trickle in. This is a potentially serious
risk. St. John’s wort should not be combined with prescription antidepressants
except on the specific advice of a physician. Because some antidepressants, such
as Prozac, linger in the blood for quite some time, persons who
have been taking such drugs should exercise caution when switching from these to
St. John’s wort. Antimigraine drugs in the triptan family (such as sumatriptan, or
Imitrex) and the pain-killing drug tramadol also raise serotonin levels and might
interact similarly with St. John’s wort.

However, perhaps the biggest concern with St. John’s wort is that it appears to
decrease the effectiveness of numerous medications, including protease
inhibitors and reverse transcriptase inhibitors (for
HIV infection), cyclosporine and tacrolimus (for organ transplants), digoxin (for
heart disease), statin drugs (used for high cholesterol), warfarin
(Coumadin, a blood thinner), chemotherapy drugs, oral contraceptives,
tricyclic
antidepressants, protein pump inhibitors (such as Prilosec),
atypical
antipsychotics such as olanzapine or clozapine (for
schizophrenia), anesthetics, and the new heart disease drug ivabradine. In fact,
there are theoretical reasons to believe that this herb might reduce the
effectiveness of, or otherwise interact with, about 50 percent of all medications.
Problems could arise, for instance, if a person is taking St. John’s wort while
also working with a physician to adjust the dosage of a particular medication to
obtain an optimum balance of efficacy and side effects. If the person subsequently
stops taking the herb, blood levels of the drug may then rise, with potentially
dangerous consequences.

Note that these proposed interactions are not purely academic; they could lead to
catastrophic consequences. Indeed, St. John’s wort appears to have caused several
cases of heart, kidney, and liver transplant rejection by interfering with the
action of cyclosporine. The herb also appears to decrease the
effectiveness of oral contraceptives and by doing so is thought to have led to
unwanted pregnancies.

On a less dramatic level, one study showed that among people taking a cholesterol-lowering medication in the statin family, use of St. John’s wort caused cholesterol levels to rise. (The same would be expected to occur if a person were using red yeast rice to treat high cholesterol, as red yeast rice supplies naturally occurring statin drugs.)

Finally, some people with HIV take St. John’s wort in the false belief that the herb will fight AIDS. The unintended result may be to reduce the potency of standard anti-HIV drugs.

There is some evidence that low-hyperforin St. John’s wort may have less potential for drug interactions than other forms of St. John’s wort. Nonetheless, it is recommended that people taking any oral or injected medication that is critical to their health or well-being entirely avoid using any form of St. John’s wort until more is known; those who are already taking the herb should not stop taking it until they can simultaneously have their drug levels monitored. It is also recommended that persons who are soon to undergo general anesthesia avoid use of the herb.

Safety in special circumstances. One animal study found no ill effects of St. John’s wort on the offspring of pregnant mice. However, these findings alone are not sufficient to establish the herb as safe for use during pregnancy. Furthermore, the St. John’s wort constituent hypericin can accumulate in the nucleus of cells and directly bind to DNA. For this reason, pregnant or nursing women should avoid St. John’s wort. Furthermore, safety for use by young children or people with severe liver or kidney disease has not been established.

Case reports suggest that, like other antidepressants, St. John’s wort can cause
episodes of mania in individuals with bipolar disorder (manic-depressive
disease). There is also one report of St. John’s wort causing temporary
psychosis in a person with Alzheimer’s disease.

Other concerns. Certain foods contain a substance called
tyramine. These foods include aged cheeses, aged or cured meats, sauerkraut, soy
sauce, other soy condiments, beer (especially beer on tap), and wine. Drugs in the
MAO
inhibitor family interact adversely with tyramine, causing
severe side effects such as high blood pressure, rapid heart rate, and delirium.
One case report suggests that St. John’s might present this risk as well. However,
other studies suggest that normal doses of the herb should not cause MAO-like
effects. Until this issue is sorted out, it is recommended that individuals taking
St. John’s wort avoid tyramine-containing foods. Since MAO inhibitors react
adversely with stimulant drugs such as Ritalin, ephedrine (found in the herb
ephedra), and caffeine, St. John’s wort should not be combined with these.

One small study suggests that high doses of St. John’s wort might slightly impair mental function. Another case report associates use of St. John’s wort with hair loss; the authors note that standard antidepressants may also cause hair loss at times.

One study raised questions about possible antifertility effects of St. John’s wort. When high concentrations of St. John’s wort were placed in a test tube with hamster sperm and ova, the sperm were damaged and less able to penetrate the ova. However, since it is unlikely that such a large amount of St. John’s wort can actually come in contact with sperm and ova when they are in the body rather than in a test tube, these results may not be meaningful in real life.

In one reported case, St. John’s wort may have interacted with the menopause drug tibolone to produce severe liver damage.

Transitioning from medications to St. John’s wort. For persons who are taking a prescription drug for mild to moderate depression, switching to St. John’s wort may be a reasonable idea if they prefer taking an herb. To avoid overlapping treatments, the safest approach is for an individual to stop taking the drug and allow it to wash out of his or her system before starting St. John’s wort. The individual should consult with his or her doctor regarding how much time is necessary.

For persons taking medication for severe depression, however, switching over to St. John’s wort is not a good idea. The herb is unlikely to work well enough for such a use, and depression could worsen to a dangerous level.

Important Interactions

Persons who are taking antidepressant drugs, including MAO inhibitors, SSRIs, and tricyclics, or possibly the drugs tramadol or sumatriptan (Imitrex), should not take St. John’s wort at the same time. To switch from such medications to St. John’s wort, individuals should let the medications flush out of their systems for a while (perhaps weeks, depending on the drug) before they start taking the herb.

Individuals who are taking digoxin, cyclosporine and tacrolimus, protease inhibitors or reverse transcriptase inhibitors, oral contraceptives, tricyclic antidepressants, warfarin (Coumadin), statin drugs, theophylline, chemotherapy drugs, newer antipsychotic medications (such as olanzapine and clozapine), anesthetics, or, indeed, any critical medication should be aware that St. John’s wort might cause such drugs to be less effective. Those who have been taking St. John’s wort while adjusting medication dosages to achieve proper blood levels should not suddenly stop St. John’s wort, as this could cause the drugs in the body to rebound to dangerously high levels.

Persons who are taking medications that cause sun sensitivity, such as sulfa drugs
and the anti-inflammatory medication piroxicam (Feldene), as well as omeprazole
(Prilosec) or lansoprazole (Prevacid), should keep in mind that St. John’s wort
might have an additive effect. Those who are taking stimulant drugs or herbs such
as Ritalin, caffeine, or ephedrine
(ephedra) should be aware that St. John’s wort might interact adversely with these
substances.

Bibliography

Bjerkenstedt, L., et al. “Hypericum Extract LI 160 and Fluoxetine in Mild to Moderate Depression: A Randomized, Placebo-Controlled Multi-center Study in Outpatients.” European Archives of Psychiatry and Clinical Neuroscience 255 (2005): 40-47.

Fava, M., et al. “A Double-Blind, Randomized Trial of St. John’s Wort, Fluoxetine, and Placebo in Major Depressive Disorder.” Journal of Clinical Psychopharmacology 25 (2005): 441-447.

Hebert, M. F., et al. “Effects of St. John’s Wort Hypericum perforatum on Tacrolimus Pharmacokinetics in Healthy Volunteers.” Journal of Clinical Pharmacology 44 (2004): 89-94.

Kasper, S., et al. “Continuation and Long-Term Maintenance Treatment with Hypericum Extract WS 5570 After Recovery from an Acute Episode of Moderate Depression.” European Neuropsychopharmacology 18 (2008): 803-813.

Sardella, A., et al. “Hypericum perforatum Extract in Burning Mouth Syndrome.” Journal of Oral Pathology and Medicine 37(2008): 395-401.

Uebelhack, R., J. U. Blohmer, et al. “Black Cohosh and St. John’s Wort for Climacteric Complaints.” Obstetrics and Gynecology 107 (2006): 247-255.

Uebelhack, R., J. Gruenwald, et al. “Efficacy and Tolerability of Hypericum Extract STW 3-VI in Patients with Moderate Depression.” Advances in Therapy 21 (2004): 265-275.

What is meningococcal meningitis? |

Definition

Meningococcal meningitis (MM) is an invasive bacterial form of meningitis,
an infection that causes swelling and
inflammation of the thin lining (membrane) that surrounds the brain
and spinal cord. MM, which can cause severe brain damage and is fatal if
untreated, was first described clinically in 1805 in Switzerland following an
outbreak in Geneva.

Causes

MM is caused by several different bacteria, including Neisseria
meningitidis, a gram-negative diplococcus bacterium found exclusively
in humans. A minimum of thirteen different serogroups of N.
meningitidis have been identified, based on the capsular
polysaccharide. Serogroups A, B, and C have been recognized as significant causes
of meningococcal disease.

Risk Factors

Risk factors for the invasive disease may be a combination of host,
environment, and organism strain. Recent respiratory tract infection, low
socioeconomic status, and a susceptible population increase vulnerability.
Climatic factors also influence seasonal outbreaks. In Africa, epidemics
begin during the dry season; in temperate countries, sporadic illness and
epidemics appear during the late winter and early spring.

MM is spread through direct contact with respiratory droplets of infected people. Therefore, it can be spread through close and prolonged contact with others, through sneezing or coughing, and by living close to an infected person.

Symptoms

The clinical manifestations of meningococcal disease can be quite varied,
ranging from transient fever and the presence of bacteria in the blood
(bacteremia) to fulminate disease and death occurring within
hours of clinical onset. Symptoms include intense headache, fever, nausea,
vomiting, photophobia, stiff neck, lethargy, myalgia, and a characteristic
petechial rash.

Screening and Diagnosis

MM is difficult to diagnose outside epidemics because symptoms mimic many other illnesses. Initial diagnosis can be made by clinical examination followed by a lumbar puncture showing a purulent spinal fluid. The bacteria can sometimes be seen in microscopic examinations of the spinal fluid.

Treatment and Therapy

Antimicrobial chemoprophylaxis is the primary means of preventing transmission
of invasive meningococcal disease from patients to close contacts. The
identification of the N. meningitidis serogroups and their
susceptibility test to antibiotics are important for treatment
and for control measures. A range of antibiotics, including penicillin,
ampicillin, chloramphenicol, and ceftriaxone, can treat the infection.

Prevention and Outcomes

Several surveillance data conclude that immunization with a meningococcal
vaccine offers the best intervention strategy. Routine
vaccination is also recommended for high-risk groups, including college freshmen
living in dormitories, travelers, populations experiencing outbreaks of
meningococcal disease, and persons with increased susceptibility.

There are three types of effective and safe vaccines for preventing MM: meningococcal polysaccharide vaccines, as either bivalent (groups A and C), trivalent (groups A, C, and W), or tetravalent (groups A, C, Y, and W-135); outer membrane proteins against serogroup B; and meningococcal conjugate vaccines against group C and a tetravalent A, C, Y, and W-135 conjugate vaccine.

Bibliography

Centers for Disease Control and Prevention. “Meningococcal Disease.” Available at http://www.cdc.gov.

Klein, D. L., and R. W. Ellis. “Conjugate Vaccines Against Streptococcus pneumoniae.” In New Generation Vaccines, edited by M. M. Levine at al. 2d ed. New York: Marcel Dekker, 1997.

Kvalsvig, A. J., and D. J. Unsworth. “The Immunopathogenesis of Meningococcal Disease.” Journal of Clinical Pathology 56 (2003): 417-422.

Pollard, A. J. “Global Epidemiology of Meningococcal Disease and Vaccine Efficacy.” Pediatric Infectious Disease Journal 23 (2004): S274-S279.

World Health Organization. Control of Epidemic Meningococcal Disease. 2d ed. Geneva: Author, 1998.

Describe mental health issues among the elderly?

Introduction

According to the American Psychological Association, by 2012 an estimated 20 percent of elderly Americans had some form of mental illness, although much of this illness goes undiagnosed and untreated because many of the elderly are reluctant to seek the professional help that might alleviate their conditions. Medicare benefits for conditions relating to mental illness are often less generous than those for physical disorders. Therefore, elderly people, especially those who are financially constrained, are unwilling and often unable to pay for the treatment that could offer them relief from the mental problems they are experiencing.

The elderly population in the United States is growing exponentially and is expected to continue that growth throughout the twenty-first century. According to the US Census Bureau, individuals sixty-five years of age and older made up more than 13 percent of the US population in 2012; that number is expected to increase to more than 20 percent by 2050, according to estimates by the US Department of Health and Human Services' Administration on Aging. Not only will the number of people aged sixty-five or older continue to grow, but also, with advanced medical breakthroughs, many of them are expected to survive for two or more additional decades, leading active lives and enjoying reasonably good health into their eighties or nineties. Nevertheless, it is anticipated that millions of these people will have some form of mental illness.

Common Mental Disorders

The most common mental disorder that affects elderly Americans is
dementia, with such accompanying conditions as delirium, depression, and psychosis. Many elderly individuals and their families overlook the symptoms of dementia, especially those that develop gradually. Often obvious symptoms are attributed to the normal aging process. Sometimes obvious symptoms are ignored by friends or family members in the hope that they will diminish or disappear. In the minds of many people, a degree of shame is still associated with any mental disorder, which leads them to deny even obvious symptoms.

Throughout history, many elderly individuals have exhibited eccentric behaviors and were forgetful. However, life expectancy was such that few people survived beyond their fiftieth year, and truly elderly people were seldom encountered. Their eccentricities could be shrugged off as being normal developments in the aging process. In medical circles, these behaviors were often identified as manifestations of senile psychosis.

In 1906, however, Alois Alzheimer, a German pathologist and neurologist, presented a case study of a fifty-seven-year-old woman, Auguste D., whose symptoms were classic symptoms of what has come to be called
Alzheimer’s disease. Following this patient’s death, Alzheimer studied samples excised from her brain and found amyloid plaques, or accumulations of dark protein, in the brain’s cortex and hippocampus. In his microscopic examinations of Augusta D.’s brain tissue, he found twisted tendrils of very fine fibers that he called neurofibrillary tangles. He concluded that these tangles were at the heart of this patient’s mental disorder.

Alzheimer’s disease, named after this pioneering physician, is the most prevalent type of dementia found in elderly patients. To date, the causes of this disease have not been identified definitively. It is known that those with Alzheimer’s often survive for five to twenty years following the onset of the disease and that their conditions usually become progressively worse. Many Alzheimer’s patients die from causes related to the disease.

Normal Aging Versus Dementia

Symptoms that suggest dementia may occur in elderly people who are not experiencing dementia as such. As the aging process accelerates in people over the age of sixty-five, most of them experience a decrease in their sensory abilities, with declines in vision, hearing, touch, taste, and smell. Also, many of the elderly use prescription drugs that may interact adversely with one another, causing severe behavioral changes. Physicians are well advised to obtain lists of all the medications, including over-the-counter drugs, taken by their patients.

Among the most significant behavioral changes observed among the elderly is a decrease in memory, both short-term and long-term. In people with Alzheimer’s disease, one of the first symptoms observed is a loss in short-term memory. Therefore, if older people show evidence that their short-term memory is failing, those who observe them might leap to the conclusion that they are in the early stages of Alzheimer’s. However, even some perfectly healthy people are forgetful. Absentmindedness occurs among people of all ages and may be the result of many factors other than dementia.

Another symptom of dementia is a tendency to respond to questions inappropriately or to give answers that do not make sense. Among the elderly, however, deficits in hearing can cause people to misconstrue questions. Therefore, if an elderly person answers questions inappropriately, it may suggest an auditory deficit rather than dementia.

Visual and auditory deficiencies can result in older people’s misinterpreting situations and reacting to them in ways that seem strange to those caring for them. Also, the elderly person in question might be living in a context quite different from the one that a caregiver perceives, so that conclusions reached based on the caregiver’s observations may be inaccurate. It is important to view the behaviors of the elderly realistically within the actual contexts in which they live and function.

Some behaviors that younger people exhibit may intensify as they age. This is often a normal part of aging. People who have typically been rigid and suspicious in their early years may find that such tendencies increase substantially as they age, but such an increase does not categorically indicate dementia. However, if such behaviors turn to unhealthy or obsessive paranoia, dementia may account for the change.

As the motor abilities of older people decrease, often as a result of factors such as arthritis or reduced blood flow to the brain, they may walk with difficulty and seem to be disoriented, even though they may be performing quite appropriately given the total context of the situation in which they find themselves. They may also become confused or lost in unfamiliar surroundings, but this is not a clear indication of dementia. However, if they cannot find their way in familiar surroundings, dementia may be suspected.

When dealing with the elderly, misdiagnoses of dementia are common. They must be regarded as questionable if they are based on information that has been obtained solely through observation. Neurological testing and sophisticated procedures such as magnetic resonance imaging (MRI) provide more reliable diagnoses.

Dementia

Dementia usually involves the loss of memory, particularly short-term memory, although in advanced cases, long-term memory may also be compromised. Those with dementia often have problems with language, most frequently being unable to bring forth the words they need to express themselves. This tendency may come and go as blood flow to the brain waxes and wanes.

One of the most devastating symptoms of dementia, one usually suggestive of Alzheimer’s disease, is an inability to recognize the people and objects with which patients have been most familiar. Individuals may be unable to recognize their spouses. Patients may touch objects, such as hammers or screwdrivers, but be unable to determine how they function. They also may be unable to attach names to such objects.

People with dementia often have difficulty carrying out the motor functions that most people take for granted, but this is not a categorical indication of dementia because physical incapacities such as the joint pain that accompanies arthritis may severely limit the motor skills of those with this condition. Adverse drug interactions may also account for a decline in motor skills.

Delirium

Delirium
is an acute state of mental confusion marked by difficulty in focusing, sustaining thoughts, and shifting attention. Patients may misconstrue the statements and actions of others, often reacting to them with great suspicion. Those experiencing delirium may have difficulty sleeping and may be physically disturbed and restless, resulting in dramatic swings in their moods.

The judgment of such people is often impaired, and efforts to alter such misjudgments may elicit anger from them. They may also experience either significantly increased or decreased motor activity. If these symptoms manifest themselves suddenly or fluctuate over short periods of time, the person may be experiencing delirium.

A reliable diagnosis of delirium can be made by having an electroencephalogram (EEG) performed on the patient. If an EEG reveals a marked decrease in cerebral activity, delirium is likely to be the cause. When such a diagnosis is made, the condition may be treated with medications that can reduce the symptoms.

Manifestations of Psychosis

Various forms of
psychosis may afflict the elderly. The most common occur in the elderly with schizophrenia or bipolar disorder. Among elderly patients diagnosed with schizophrenia or bipolar disorder, many may also have delirium or dementia.

Schizophrenia
, a chronic brain disorder, is characterized by hallucinations and delusional thinking or behavior. Although schizophrenia is rare among people over the age of sixty-five, it can be a very disturbing and potentially dangerous condition. Most people with schizophrenia develop it in the second or third decade of life, but some are first diagnosed between the ages of forty and sixty-five, and others are diagnosed after reaching the age of sixty-five. Late-onset schizophrenia-like psychosis is more common in women and is characterized by paranoia, brain structure abnormalities, and cognitive deterioration. A family history of schizophrenia and a history of early childhood problems are usually absent. Schizophrenia differs from Alzheimer’s disease in that hallucinations tend to be auditory rather than visual, delusions tend toward the bizarre, and patients usually recognize their caregivers. Elderly people who have schizophrenia are usually treated with antipsychotic medications. Psychosocial treatment such as cognitive behavior therapy and social skills training can also be helpful.

Bipolar disorder causes significant and often sudden mood swings in which patients fluctuate from the depressive state to the manic state, which sometimes reaches psychosis. Manic periods are characterized by heightened mood (irritability or euphoria), grandiosity, decreased sleep, and, in severe cases, a loss of touch with reality. Depression is a universal condition and is perfectly normal in most people, particularly if it has an identifiable cause such as loss of a job or financial difficulties. In such cases, once the cause is removed or controlled, the depression usually moderates. However, those with bipolar disorder, like the clinically depressed, are depressed for no apparent reason. They experience down moods that may be so pervasive that they can lead to such drastic outcomes as suicide, which is a major cause of death among those over the age of sixty-five. Bipolar disorder is most commonly treated with mood-stabilizing drugs such as lithium.

Clinical Depression

The elderly are more subject to
depression than is the general population, partly because they are at a point in their lives when their spouses and close friends are dying, leaving the survivors feeling isolated and hopeless. This factor is combined with the physical deterioration that is part of aging. The diagnosis of severe, or clinical, depression is sometimes difficult because many people will not admit that they are depressed. Men experiencing deep depression may view such feelings as unmanly. Women who fight depression are often less skillful than men at masking their depression. Those dealing with them must understand various nuances that may suggest the condition.

Among these nuances, one of the most common is hypochondria. People who are basically healthy and organically sound may experience imaginary ills that are, to them, quite real. Overworked physicians may simply dismiss such patients because they cannot find anything wrong with them. A sensitive physician, however, will probe deeply enough to find the real cause of the patient’s hypochondria and will avoid treating it medicinally until the basic causes have been uncovered.

Various behaviors provide the clues that signal a patient’s depression. Among the most common of these are severe declines in self-image, often accompanied by dramatic decreases or increases in appetite; loss of interest in sex; difficulty in concentrating; loss of memory; reduction of motor skills; and significant declines in energy levels. People entering a depressive state may experience substantial gains or losses in weight. The clinically depressed may have seemingly unjustified feelings of guilt. They may experience physical manifestations such as a tightness in the chest or unexplained difficulty in breathing. They may also harbor thoughts of suicide and may have gone so far as to plan or to have attempted suicide.

Depression in the elderly can be treated with medications, but also can be dealt with successfully in many cases by making changes in lifestyle, such as becoming more actively involved socially. Seeing films and plays with friends and then discussing what they have seen or playing board games or card games can be a useful therapy for some elderly people. Many older people benefit greatly from participating in book clubs.

Nutrition and exercise are also major components in maintaining the mental health of the elderly, who should eat three well-balanced meals a day and consume at least five portions of fresh vegetables and fruits daily. The elderly should limit their intake of alcohol and refrain from smoking. Regular activities such as walking, cycling, swimming, water aerobics, or yoga can help restore flexibility to aging joints and, if engaged in judiciously, can prolong one’s active life. Exercise and proper nutrition often do more to control depression than any medication can.

Bibliography

Barker, L. Randol, and Philip D. Zieve, eds. Principles of Ambulatory Medicine. 7th ed. Philadelphia: Lippincott, 2007. Print.

Brody, Claire M., and Vicki G. Semel, eds. Strategies for Therapy with the Elderly: Living with Hope and Meaning. 2d ed. New York: Springer, 2006. Print.

Budson, Andrew E., and Neil W. Kowall. The Handbook of Alzheimer's Disease and Other Dementias. Chichester: Wiley, 2014. Print.

Capezuti, Elizabeth A., et al., eds. The Encyclopedia of Elder Care. 3rd ed. New York: Springer, 2014. Print.

Evans, Sandra, and Jane Garner, eds. Talking over the Years: A Handbook of Dynamic Psychotherapy with Older Adults. New York: Brunner-Routledge, 2004. Print.

Levine, Robert V. Defying Dementia: Understanding and Preventing Alzheimer’s and Related Disorders. Westport: Praeger, 2006. Print.

"Mental and Behavioral Health and Older Americans." American Psychological Association. APA, 2014. Web. 15 May 2014.

Mondimore, Francis Mark. Bipolar Disorder: A Guide for Patients and Their Families. 2d ed. Baltimore: Johns Hopkins UP, 2006. Print.

"Projected Future Growth of the Older Population." Administration on Aging. Dept. of Health and Human Services, n.d. Web. 15 May 2014.

Rosenberg, Jessica, and Samuel J. Rosenberg, eds. Community Mental Health: Challenges for the 21st Century. 2nd ed. New York: Routledge, 2013. Print.

Sabbagh, Marwan Noel. The Alzheimer’s Answer: Reduce Your Risk and Keep Your Brain Healthy. Hoboken: Wiley, 2008. Print.

Tallis, Raymond C., and Howard M. Fillit, eds. Brocklehurst’s Textbook of Geriatric Medicine and Gerontology. 6th ed. London: Churchill, 2003. Print.

"USA." United States Census Bureau. US Dept. of Commerce, 27 Mar. 2014. Web. 15 May 2014.

Wetherell, Julie Loebach, and Dilip V. Jeste. “Older Adults with Schizophrenia: Patients Are Living Longer and Gaining Researchers’ Attention.” Elder Care 3.2 (2003): 8–11. Print.

What is the theme or central message of The BFG by Roald Dahl?

The BFG by Roald Dahl is a children's book. The book is narrated through the eyes of Sophie, a young orphan, and describes her life after she encounters the BFG (Big Friendly Giant). Initially, Sophie is frightened of the BFG and worries he will eat her, but they eventually become friends and save England from evil giants.

The main message of the story has to do with real morality versus conventions. Although the BFG appears...

The BFG by Roald Dahl is a children's book. The book is narrated through the eyes of Sophie, a young orphan, and describes her life after she encounters the BFG (Big Friendly Giant). Initially, Sophie is frightened of the BFG and worries he will eat her, but they eventually become friends and save England from evil giants.

The main message of the story has to do with real morality versus conventions. Although the BFG appears frightening on the surface and does not follow the conventions of polite society, he is a morally good character, showing what matters is character, not external appearances or circumstances. The BFG and Sophie are both despised outcasts, but prove themselves heroic. Trust and friendship can overcome the barriers between even the most superficially different people. As shown in BFG's treatment of his opponents, it is always important to choose fair and just means to achieve one's ends.

In The Great Gatsby, how is Daisy portrayed as a "Golden Girl" and what are some examples?

Nick describes Daisy as the golden girl, in large part, because of her money.  She has a lot of it, and she acts and speaks as though she has a lot of it. He says that the money in her voice

was the inexhaustible charm that rose and fell in it, the jingle of it, the cymbals' song of it . . . . High in a white palace the king's daughter, the golden girl...

Nick describes Daisy as the golden girl, in large part, because of her money.  She has a lot of it, and she acts and speaks as though she has a lot of it. He says that the money in her voice

was the inexhaustible charm that rose and fell in it, the jingle of it, the cymbals' song of it . . . . High in a white palace the king's daughter, the golden girl . . . .

Daisy speaks with the confidence of someone who has always been treated as though she were special; she conducts herself with the bearing of one who has always been set apart.  She is beautiful and rich, and no one has ever really refused her anything she's wanted.  This has made her self-centered and selfish, elitist, and sort of cruel. 

When Nick first arrives at her home in chapter one, she reproaches him because he "didn't come to [her] wedding." He reminds her that he was in the war. She goes on and on about the "very bad time" she's had, failing to consider that Nick probably had a far worse time in the war: she's unbelievably self-centered. Further, she states, with "thrilling scorn. 'Sophisticated -- God, I'm sophisticated!'" and then

"looked at [Nick] with an absolute smirk on her lovely face, as if she had asserted her membership in a rather distinguished secret society to which she and Tom belonged."

Daisy is like a princess in a castle, and she knows it.  She may seem to hold this fact in contempt at times, but she is ultimately too attached to her status to relinquish it.  For these reasons, Nick calls her "the golden girl."

How can one write about Romanticism in Jane Eyre?

First, you could start by defining the elements of Romanticism on which you plan to focus in your paper. Several aspects of Romanticism relevant to Jane Eyre include first, an emphasis on the ordinary person, second, an emphasis on emotion over reason and third, an emphasis on the supernatural. You could talk about how Jane is an ordinary person, small, an orphan, a governess, not very attractive (she is described as "plain") and insignificant in...

First, you could start by defining the elements of Romanticism on which you plan to focus in your paper. Several aspects of Romanticism relevant to Jane Eyre include first, an emphasis on the ordinary person, second, an emphasis on emotion over reason and third, an emphasis on the supernatural. You could talk about how Jane is an ordinary person, small, an orphan, a governess, not very attractive (she is described as "plain") and insignificant in the eyes of the world, yet like the mouse in Robert Burns "To a Mouse" poem pulses with life in her own sphere. You could then talk about the intense passions both Jane and Rochester feel--the quotes link has a quote about Jane's tendency to extreme emotions. Finally, you could focus on the scene near the end of the novel, where Jane has a supernatural experience and runs to Rochester when she hears him calling out to her in a dream, only to find his home burned to the ground and Rochester in need of her. Picking out three aspects of Romanticism in the novel and finding quotes or examples to illustrate them is a good way to go about writing a two page paper. 

How is Juliet's attitude in Act III, Scene 2 like that of Romeo in Act I, Scene 1 of Romeo and Juliet, and are there any significant differences?...

Romeo and Juliet, who feel mixed emotions, both recognize in their speeches that life is contradictory and confusing, and their use of oxymoron reflects this understanding.

In Act I, Scene 1, an emotional Romeo talks with his friend Benvolio after the street fight in which the houses of Capulet and Montague have engaged. When Romeo says, "Here's much to do with hate, but more with love" (1.1.170), he expresses his puzzlement with the fine line...

Romeo and Juliet, who feel mixed emotions, both recognize in their speeches that life is contradictory and confusing, and their use of oxymoron reflects this understanding.

In Act I, Scene 1, an emotional Romeo talks with his friend Benvolio after the street fight in which the houses of Capulet and Montague have engaged. When Romeo says, "Here's much to do with hate, but more with love" (1.1.170), he expresses his puzzlement with the fine line that exists between the two emotions, as well as the swiftness with which one emotion can transform into the other. Further, he also recognizes that emotions become entangled with one another and often are hard to distinguish, as he employs this oxymoron: "Misshapen chaos of well-seeming forms!" (1.1.175).

Similarly, after having excitedly anticipated her loving hours to come with her new husband, Juliet experiences exaggerated and conflicting feelings when she learns of Tybalt's death at the hands of Romeo. An emotional Juliet feels both deceived and betrayed while still in love with Romeo:

O serpent heart, hid with a flowering face!
Did ever dragon keep so fair a cave?
Beautiful tyrant! fiend angelical!— (3.2.74-76)

Like Romeo, Juliet, too, expresses her tangled emotions through the use of oxymorons as beautiful feelings and conflicting ideas become intermixed. However, although Juliet is focused only on one issue—the betrayal that she feels because her beloved Romeo has slain her cousin Tybalt—Romeo's contemplation of his lost love of Rosaline is interrupted as he notices Benvolio's wound. It is then that he speaks of the feud, until near the end of his speech as he resumes his contemplation of Rosaline. And, at this point, he bemoans the loss of her love: "This love feel I, that feel no love in this" (1.1.172). So, for Romeo, there is an even greater intermingling of emotions than there is for Juliet.

What are Montresor's verbal and non-verbal strategies of initially engaging Fortunato and then luring him along throughout the story "The Cask of...

Montresor tricks Fortunato into coming into the crypt by using reverse psychology on him and trying to keep him at ease.

Montresor’s main strategy is to pretend that he does not want Fortunato to come see the wine.  First he implies that it would be better to let someone else look at it.  Then he continually inquires about Fortunato’s health, implying that he is too ill to remain.  He makes jokes to prevent Fortunato from knowing what is happening, and indeed the victim has no idea until he is already in the wall.

The first non-verbal cue Montresor gives Fortunato is shaking his hand.  He makes him think that he is happy to see him because they are friends. The reality is that he is happy to see him because he has a carefully orchestrated plan to kill him.  It would be a shame to let such a plan go to waste.  Fortunato is drunk, because of the Carnival.  His guard is down.

Montresor tells Fortunato that he has a special cask of wine that he needs an opinion on.  He knows that if he tells Fortunato that someone else will look at it, Fortunato will not be able to resist.  He also pretends to worry about Fortunato’s cold, so that the man will not realize how badly he wants him to go underground.

"My friend, no. It is not the engagement, but the severe cold with which I perceive you are afflicted. The vaults are insufferably damp. They are encrusted with nitre."

"Let us go, nevertheless. The cold is merely nothing. Amontillado! You have been imposed upon. And as for Luchresi, he cannot distinguish Sherry from Amontillado."

Montresor succeeds in getting Fortunato underground.  Once there, he uses a combination of verbal and nonverbal cues.  He jokes about being a member of the Masons, a secret society, and shows Fortunato the trowel.

"You? Impossible! A mason?"

"A mason," I replied.

"A sign," he said, "a sign."

"It is this," I answered, producing from beneath the folds of my roquelaire a trowel.

"You jest," he exclaimed, recoiling a few paces. "But let us proceed to the Amontillado."

The trowel gesture is designed to keep Fortunato at ease, making him think that everything is okay and it is all a joke.  It also explains away the presence of the trowel.  Montresor does not believe that Fortunato will question his having it now that he has shown it to him.  In fact, that is pretty much what happens.  Fortunato still thinks it is a joke until he is being bricked up in the wall.