By M. Onatas. Case Western Reserve University.
Hepatitis A outbreaks have been related to fecally contaminated water best 40mg esomeprazole, food contaminated by infected food handlers cheap esomeprazole 20 mg free shipping, including sandwiches and salads that are not cooked or are handled after cooking cheap esomeprazole 40mg online, and raw or undercooked mollusks harvested from contaminated waters. Aseptic meningitis, polio, and viral gastroenteritis (Norwalk agent) are other viral diseases that can be transmitted through water. Most viruses in drinking water can be inactivated by chlorine or other disinfectants. Terrorism Recent investigations have shown proof the terrorist organizations have been able to reproduce most of these pathogens and have the technology and funding to attack our public water supply system. Even diseases that we have not seen in years are easily and readily available for a terrorist to backflow into our distribution system, or pour into a wellhead or clearwell. Waterborne Diseases ©6/1/2018 18 (866) 557-1746 The Main Players - History and Biology Chapter 1 Before we define the major waterborne diseases, let’s first examine the germs and other creatures that cause the diseases. Most of the following information may be simple or instruction that you already know. History of Research By the last half of the 19th century, the microbial world was known to consist of protozoa, fungi, and bacteria, all visible with a light microscope. In the 1840s, the German scientist Jacob Henle suggested that there were infectious agents too small to be seen with a light microscope, but for the lack of direct proof, his hypothesis was not accepted. Although the French scientist Louis Pasteur was working to develop a vaccine for rabies in the 1880s, he did not understand the concept of a virus. During the last half of the 19th century, several key discoveries were made that set the stage for the discovery of viruses. Pasteur is usually credited for dispelling the notion of spontaneous generation and proving that organisms reproduce new organisms. The German scientist Robert Koch, a student of Jacob Henle, and the British surgeon Joseph Lister developed techniques for growing cultures of single organisms that allowed the assignment of specific bacteria to specific diseases. Waterborne Diseases ©6/1/2018 19 (866) 557-1746 First Experiment The first experimental transmission of a viral infection was accomplished in about 1880 by the German scientist Adolf Mayer, when he demonstrated that extracts from infected tobacco leaves could transfer tobacco mosaic disease to a new plant, causing spots on the leaves. Because Mayer was unable to isolate a bacterium or fungus from the tobacco leaf extracts, he considered the idea that tobacco mosaic disease might be caused by a soluble agent, but he concluded incorrectly that a new type of bacteria was likely to be the cause. The Russian scientist Dmitri Ivanofsky extended Mayer’s observation and reported in 1892 that the tobacco mosaic agent was small enough to pass through a porcelain filter known to block the passage of bacteria. But Ivanofsky, like Mayer, was bound by the dogma of his times and concluded in 1903 that the filter might be defective or that the disease agent was a toxin rather than a reproducing organism. Unaware of Ivanofsky’s results, the Dutch scientist Martinus Beijerinck, who collaborated with Mayer, repeated the filter experiment but extended this finding by demonstrating that the filtered material was not a toxin because it could grow and reproduce in the cells of the plant tissues. In his 1898 publication, Beijerinck referred to this new disease agent as a contagious living liquid—contagium vivum fluid—initiating a 20-year controversy over whether viruses were liquids or particles. The conclusion that viruses are particles came from several important observations. Because each hole, or plaque, developed from a single bacteriophage, this experiment provided the first method for counting infectious viruses (the plaque assay). In 1935 the American biochemist Wendell Meredith Stanley crystallized tobacco mosaic virus to demonstrate that viruses had regular shapes, and in 1939 tobacco mosaic virus was first visualized using the electron microscope. Frosch (both trained by Robert Koch) described foot-and-mouth disease virus as the first filterable agent of animals, and in 1900, the American bacteriologist Walter Reed and colleagues recognized yellow fever virus as the first human filterable agent. For several decades viruses were referred to as filterable agents, and gradually the term virus (Latin for “slimy liquid” or “poison”) was employed strictly for this new class of infectious agents. Through the 1940s and 1950s many critical discoveries were made about viruses through the study of bacteriophages because of the ease with which the bacteria they infect could be grown in the laboratory. Germ Theory of Disease History Louis Pasteur along with Robert Koch developed the germ theory of disease which states that "a specific disease is caused by a specific type of microorganism. Koch’s postulates not only proved the germ theory but also gave a tremendous boost to the development of microbiology by stressing a laboratory culture and identification of microorganisms. Circumstances under which Koch’s postulates do not easily apply • Many healthy people carry pathogens but do not exhibit the symptoms of disease. These "carriers" may transmit the pathogens to others who then may become diseased. Example: viruses, chlamydia, rickettsias, and bacteria that cause leprosy and syphilis. Some of the fastidious organisms can now be grown in cultures of human or animal cells or in small animals. These secondary invaders or opportunists cause disease only when a person is ill or recovering from another disease. For example, in the case of pneumonia and ear infections following influenza, isolation of bacteria causing pneumonia may mislead the isolation of influenza virus. Still others, such as cancer of the lungs and skin, are influenced by environmental factors. Cells Robert Hooke observed small empty chambers in the structure of cork with the help of his crude microscope. With the help of advanced microscopes it is now known that a cell is composed of many different substances and contains tiny particles called organelles that have important functions. Rudolph Virchow completed the cell theory with the idea that all cells must arise from preexisting cells. In biology, a cell is defined as the fundamental living unit of any organism and exhibits the basic characteristics of life. A cell obtains food from the environment to produce energy and nutrients for metabolism.
The most common technique is resection of the coar- ctation segment and end-to-end anastomosis via a left lateral thoracotomy incision purchase 20mg esomeprazole. An alternative technique is the subclavian flap esomeprazole 20mg free shipping, which involves using the left subclavian artery to augment the narrow aortic segment and replace resected tissue buy esomeprazole 20mg mastercard. Over time, the left upper extremity will be supplied by collateral arteries that develop in lieu of the resected subclavian artery. As a result, the left upper extremity may be smaller than the right upper extremity. Following repair of coarctation, patients may develop varying degrees of reco- arctation and will require life-long cardiology follow-up. If significant recoarcta- tion develops, patients are usually treated by balloon angioplasty with possible stent placement in the coarctation segment. Patients who present later in life with coarctation of the aorta are usually treated by balloon angioplasty with stent placement of the coarctation segment. Stent use is avoided in younger children since the stent may not be possible to dilate to adult aortic arch diameter dimensions. A 10-year-old male patient presents to his pediatrician’s office for a regu- lar checkup. His past medical history is remarkable for occasional headaches, but the patient otherwise has no complaints. Initial vital signs are notable for elevated blood pressure (154/78 mmHg) in the right upper extremity. In general, the patient is well devel- oped and well appearing, in no acute distress. On auscultation, the patient is noted to have a 3/6 systolic murmur in the left infraclavicular area. On recheck of the patient’s triage vital signs, the patient is noted to have a blood pressure of 159/79 mmHg in the upper extremity and 110/60 mmHg in the lower extremity. The differential diagnosis for hypertension includes essential hypertension, endocrine disorders, renovascular disease, or cardiac causes, such as coarctation of the aorta or conditions associated with a large stroke volume; the differential blood pressure between upper and lower extremities strongly suggests coarctation of the aorta. Associated cardiac defects, including bicuspid aortic valve and ventricular septal defect, are not found. The patient undergoes percutaneous balloon angioplasty with stent placement given in his older age at presentation and the ability to dilate implanted stent in the future to adult dimensions. A 10-day-old newborn presents to the emergency room with increased irritability and poor feeding in the last 2–3 days. He was born full term via normal vaginal delivery with no history of complications during pregnancy. He did well in the first week of life, but started to have episodes of intermittent irritability and decreased oral intake in the last 3 days with noticeable ashen discoloration. Mother denies fever, vomiting, diarrhea, or history of illnesses with other family members. However, pulses were markedly diminished in all four extremities with reduced capillary refill (4 s). This infant is demonstrating signs of acute circulatory shock, without respiratory distress. His clinical picture is suggestive of a left heart obstructive lesion, including subaortic obstruction secondary to hypertrophic cardiomyopathy and septal hypertrophy, critical aortic stenosis, coarctation of the aorta, interrupted aortic arch, or hypoplastic left heart syndrome. The patient is emergently started on prostaglandin to maintain patency of the ductus arteriosus resulting in the improvement of systemic perfusion. Given the early onset of symptom in this child, surgery with resection of the coarctation segment and end-to-end anastomosis of the aortic segments is planned once the child is stabilized from metabolic acidosis secondary to shock. His parents are counseled that he will need life-long cardiology follow-up to assess for recurrence of the coarctation and possible future need for balloon dilation of recoarctation of the aorta. Homograft valves (and other biological material) are used for this type of repair. Definition Tetralogy of Fallot is the most common cyanotic congenital heart disease. In addition the anterior displacement of the outflow septum will result in narrowing of the right ventricular outflow tract and pulmonary stenosis. Right ventricular hypertrophy results from obstruction of flow at the right ventricular outflow tract and pulmonary valve. There is, however, a tendency toward genetic or chromosomal abnormalities such as DiGeorge and Down syndromes. There are other, more rare forms which generally vary based on the severity of the pulmonary stenosis. Blood can flow back and forth across this area without restriction which often results in very large, dilated pulmonary arteries. The main focus in this chapter will be on the more common lesion with the four classic components. Pulmonary stenosis causes increased resistance to blood flow into the pulmonary circulation and encourages blood flow from the right ventricle into the overriding aorta. Therefore, blood that would normally flow into the pulmonary artery shunts right to left to the systemic circulation causing reduced pulmonary blood flow and cyanosis. Cyanosis is a product of the right to left shunting at the ventricular level as well as the reduced volume of pulmonary blood flow resulting in less oxygenated blood return to the left atrium. Once born, newborn children are frequently asymptomatic and often do not exhibit cyanosis. The first heart sound is normal while the second heart sound is often single, loud, and accentuated. This is due to the lack of pulmonary valve component of the second heart sound due to its defor- mity. A harsh crescendo–decrescendo systolic ejection murmur is appreciated at the upper left sternal border due to flow of blood across the narrowed pulmonary valve (Fig.
Differential diagnosis Bullous pemphigoid buy discount esomeprazole 20mg line, cicatricial pemphigoid discount esomeprazole 40mg amex, linear IgA disease purchase esomeprazole 40mg with amex, pemphigus, herpetiform ulcers. Bullous Lichen Planus Definition Bullous lichen planus is a rare formof lichen planus (see p. Clinical features It is clinically characterized by the formation of bullae that soon rupture, leaving painful shallow ulcerations (Fig. The bullae usually arise on a background of papules or striae with the typical pattern of lichen planus. Usage subject to terms and conditions of license 128 Vesiculobullous Lesions Laboratory tests Histopathological examination, direct immunofluo- rescence. Differential diagnosis Cicatricial pemphigoid, linear IgA disease, pem- phigus, erythema multiforme, drug reactions. Epidermolysis Bullosa Definition Epidermolysis bullosa is a heterogeneous group of usually inherited mucocutaneous bullous disorders. Clinical features Depending on the defective mechanism of cellular cohesion, three main inherited groups are recognized: simplex, junc- tional, and dystrophic. The clinical spectrumand the degree of severity may range from mild to severe or fatal. Oral lesions present as bullae, usually in areas of friction, which rupture, leaving shallow ulcers, and later atrophy and scarring (Figs. Skin lesions are characterized by the formation of bullae, followed by ulcerations and scarring, particularly in areas exposed to low-grade chronic trauma (Figs. Nail involvement, deformities of hands and feet, milia formation, and involvement of the larynx, pharynx, and esophagus are common in the recessive dystrophic type. Usage subject to terms and conditions of license 130 Vesiculobullous Lesions Laboratory tests Histopathological and immunohistochemical exami- nation. Differential diagnosis Pemphigus, cicatricial and bullous pemphigoid, linear IgA disease, bullous dermatoses of childhood, epidermolysis bul- losa acquisita. Usage subject to terms and conditions of license 132 Vesiculobullous Lesions Epidermolysis Bullosa Acquisita Definition Epidermolysis bullosa acquisita is a rare, noninherited, chronic mechanobullous disease involving the skin and mucous mem- branes. Clinical features The skin lesions present as hemorrhagic bullae and ulcerations usually at the sites of mechanical irritation. The dorsumof the hands and arms, feet, knees, and elbows are more frequently affected. The oral lesions are common (over 50%) and present as solitary or multiple bullae and painful ulcerations (Fig. Gingival involvement may present as desquamative gingivitis or as localized bullae that rupture, leaving pain- ful ulcerations. Laboratory tests Histopathological examination, direct and indirect immunofluorescent tests. Differential diagnosis Cicatricial pemphigoid, bullous pemphigoid, linear IgA disease, pemphigus, genetic epidermolysis bullosa, dermatitis herpetiformis, chronic ulcerative stomatitis, angina bullosa hemorrhag- ica, systemic lupus erythematosus, porphyria cutanea tarda. Systemic and/or topical corticosteroids, immunosuppres- sives, colchicine, immunoglobulin. Usage subject to terms and conditions of license 134 Vesiculobullous Lesions Angina Bullosa Hemorrhagica Definition Angina bullosa hemorrhagica is a rare acute and benign blood blistering oral disorder. However, mild trauma and the chronic use of steroid inhalers seemto play an important role in the development of the lesions. Clinical features Clinically, it appears as single or multiple hemorrhag- ic bullae that rupture spontaneously within hours or 1–2 days, leaving superficial ulcerations that heal without scarring in 5–10 days (Figs. However, laboratory tests are sometimes necessary to rule out any other bullous diseases. Differential diagnosis Epidermolysis bullosa acquisita, cicatricial pemphigoid, bullous pemphigoid, linear IgA disease, pemphigoid gesta- tionis, pemphigus, bullous lichen planus, amyloidosis, blood dyscrasias. Usage subject to terms and conditions of license Laskaris, Pocket Atlas of Oral Diseases © 2006 Thieme All rights reserved. Usage subject to terms and conditions of license 137 5 Ulcerative Lesions Ulcerative lesions are a group of common oral mucosal disorders. The most common causes of these lesions are mechanical and reactive factors, infectious diseases, and neoplasms, as well as autoimmune and hematological disorders. The main clinical feature in all these conditions is an ulcer, which is defined as loss of all epithelial layers. In addition, the term “erosion” is used to defined a superficial loss of epithelium. How- ever, at the clinical level, the terms “ulcer” and “erosion” are usually used interchangeably. In this chapter, only primary ulcerative lesions are discussed, and not lesions that arise secondarily fromruptured bullae. O Traumatic ulcer O Noma O Eosinophilic ulcer O Syphilis O Necrotizing sialadenometa- O Tuberculosis plasia O Systemic mycoses O Necrotizing ulcerative gingi- O Recurrent aphthous ulcers vitis O Behçet disease O Necrotizing ulcerative stoma- O Graft-versus-host disease titis O Wegener granulomatosis O Chronic ulcerative stomatitis O Malignant granuloma Laskaris, Pocket Atlas of Oral Diseases © 2006 Thieme All rights reserved. Clinical features They are clinically diverse, but usually appear as a single, painful ulcer with a smooth red or whitish-yellow surface and a thin erythematous halo (Figs. They are usually soft on palpation, and heal without scarring within 6–10 days, spontaneously or after removal of the cause. However, if an ulcer persists over 10–12 days a biopsy must be taken to rule out cancer. Differential diagnosis Squamous-cell carcinoma and other malignan- cies, eosinophilic ulcer, aphthous ulcer, Riga–Fede disease, syphilis, tu- berculosis, systemic mycoses. Usage subject to terms and conditions of license 140 Ulcerative Lesions Eosinophilic Ulcer Definition Eosinophilic ulcer, or traumatic ulcerative granuloma with eosinophilia, is a rare, often self-limiting, benign lesion of the oral mucosa not related to Langerhans cell histiocytosis.
Lipoid Proteinosis Lipoid proteinosis cheap esomeprazole 40 mg with mastercard, or hyalinosis cutis et mucosae purchase esomeprazole 20mg otc, or Urbach-Wiethe disease 40 mg esomeprazole for sale, is a rare hereditary metabolic disorder transmitted as an autosomal recessive trait. The disease primarily affects the skin, oral mucosa, larynx, and rarely other organs. It is characterized by the deposition of an amor- phous hyaline-like material (glycoprotein) in the mucous membranes and skin. Clinically, the early skin changes are characterized by the presence of papules, nodules, and pustules (Fig. These acnelike scars, although more evi- dent on the face, are also seen on other skin regions. Verrucous hyperkeratotic lesions in areas exposed to pressure or trauma may also occur. The face, eyelid margin, pressure, and exposed areas are the most frequently affected sites. In young patients the oral changes consist of induration of the lip mucosa and the posterior part of the tongue. By the second decade, granular lesions appear on the lip and papular lesions on the palate and tongue. Metabolic Diseases Glycogen Storage Disease Type 1 b Xanthomas The glycogen storage diseases are a group of Xanthomas are papules, nodules, or plaques of genetic disorders involving the metabolic path- yellowish color that are due to lipid deposits in the ways of glycogen. The major lipid stored is usu- rare severe autosomal recessive metabolic disease ally cholesterol ester, although in some cases tri- caused by a defect in the microsomal translocase glycerides are primarily present. The clinical features of classified into several forms and frequently repre- the disease are hypoglycemia, hyperlipidemia, sent the hallmark of particular syndromes. The hepatomegaly, delayed physical development, clinical importance of xanthomas is the fact that bleeding diathesis, short stature, hepatic their presence implies an underlying disease. Oral of the extremities, and in areas of friction and manifestations are frequent and include rapidly repeated minor trauma. The oral mucosa is a rare progressive periodontal disease and recurrent ul- location of xanthomas, although they may develop ceration. The oral ulcers appear as discrete, deep, on the lips, gingiva, alveolar mucosa, mucobuccal punched-out lesions a few millimeters to several fold, and buccal mucosa. Clinically, they present centimeters in size, usually covered by whitish as well-circumscribed yellowish plaques that may pseudomembranes (Fig. Metabolic Diseases Porphyrias Hemochromatosis Porphyrias are a rare group of disorders charac- Hemochromatosis is an iron-storage disorder of terized by a defect in porphyrin metabolism, unknown cause resulting in deposition of large resulting in overproduction of porphyrins and amounts of iron in the internal organs. The types: erythropoietic (congenital erythropoietic skin acquires a generalized gray-brown pigmenta- porphyria, erythropoietic coproporphyria), hepat- tion in almost all cases. The oral mucosa shows ic (acute intermittent porphyria, variegate por- diffuse homogeneous pigmentation of gray-brown phyria, Chester porphyria, porphyria cutanea or deep brown hue in about 20% of the cases. The tarda, hereditary coproporphyria), and eryth- buccal mucosa and the attached gingiva are the rohepatic (erythrohepatic protoporphyria, hepato- most frequently involved sites (Fig. Photosensitivity of the tion, major and minor salivary gland involvement skin is seen in almost all types of porphyria. Light-exposed areas of the skin are primarily affected, along with systemic signs and Laboratory tests. Routine laboratory tests may reveal evidence of diabetes mellitus and liver dys- symptoms. In addition, the serum determination of rare genetic type characterized by severe cutane- iron, transferrin, and ferritin are helpful in estab- ous lesions, hemolytic anemia, and splenomegaly. Under ultraviolet light, the teeth exhibit a characteristic reddish pink fluorescence. However, erythema, vesicles, bullae, ulcers, atrophy but no scarring may appear in congenital erythropoietic porphyria and occasion- ally in porphyria cutanea tarda. The oral lesions usually develop on the vermilion border of the lips, commissures, labial mucosa, anterior vestibu- lar alveolar mucosa, and gingiva (Figs. The differential diagnosis includes epidermolysis bullosa, chronic bullous diseases, lipoid pro- teinosis, pellagra, and drug-induced photosen-sitivity. Laboratory tests to establish the diagnosis are biochemical tests, histopathologic examination, and direct immunofluorescence. It The disease is characterized by dysfunction of the is one of the most poorly defined, clinically exocrine glands, particularly the exocrine pan- heterogeneous, diagnostically variable, and prog- creas, bronchial, tracheal, and gastrointestinal nostically unforeseeable clinical entities. The cardinal manifestations are ease spectrum includes three varieties: Letterer- chronic pulmonary infections, pancreatic insuffi- Siwe disease, Hand- Schuller-Christian disease, ciency, cirrhosis, skeletal disorders, and skin and eosinophilic granuloma. The salivary glands are affected as part ease is the acute disseminated form, which usually of the generalized exocrine gland involvement. Elevated Hand -Schuller-Christian disease is the levels of chloride, potassium and sodium in sweat chronic disseminated form, which has a more and lack of pancreatic enzymes in the duodenal benign course. It usually appears between 3 and 6 fluid are the most reliable diagnostic tests for years of age and affects predominantly boys (2: 1 cystic fibrosis. The oral cavity is fre- quently involved in the early stages of the disease, with ulcers, edema, hyperplasia, and necrosis of the gingiva, halitosis, and bad taste (Fig. In cases of involvement of the jaw bones there is loosening of the teeth and severe periodontitis 25. Eosinophilic granuloma, ulcer, and bone destruction of the periodontal tissues between the central and lateral incisor teeth. Delayed healing of The differential diagnosis includes eosinophilic tooth sockets after extraction may be seen. Histopathologic examination and asymptomatic monostotic or polyostotic osteolytic radiographs of the involved areas help to establish bone lesions, and on rare occasions there may be the diagnosis.
Put a dab of the Quick Cornstarch Softener recipe on top of each wipe as you use it buy discount esomeprazole 20mg online. Vitamin C powder (you may crush tablets) ¼ cup vegetable glycerin 1 cup water Prepare wipes by cutting paper towels in quarters order esomeprazole 40 mg on-line. Try several on yourself (bring a small mirror) in the store to see what hardness suits you discount 40 mg esomeprazole visa. To check this out for yourself, close your eye tightly and then dab lemon juice on your eyelid. Mix glycerin and water, half and half, and add it to the charcoal powder until you get the consistency you like. To make the lipstick stay on longer, apply 1 layer of lipstick, then dab some corn starch over the lips, then apply another layer of lipstick. Store in a small glass or plastic container in the refrigerator, tightly covered in a plastic bag. Blush (face powder in a cake form) Add 50% glycerin to cornstarch in a saucer to make a paste. Try to make the consistency the same as your brand name product, and you can even put it back in your brand name container. Recipes For Household Products Floor Cleaner Use washing soda from the grocery store. Use white distilled vinegar in your rinse water for a natural shine and ant repellent. Never use chlorine bleach if anybody in the home is ill or suffers from depression. Use grain alcohol (1 pint to 3 quarts water) for germ killing action instead of chlorine. Furniture Duster and Window Cleaner Mix equal parts white distilled vinegar and water. Since boric acid is white, you must be careful not to mistake it for sugar accidentally. Ant Repellent Spray 50% white distilled vinegar on counter tops, window sills and shelves and wipe, leaving residue. Start early in spring before they arrive, because it takes a few weeks to rid yourself of them once they are established. If you want immediate action, get some lemons, cut the yellow outer peel off and cover with grain alcohol in a tightly closed jar. To treat the whole house, pour vinegar all around your foundation, close to the wall, using one gallon for every five feet. Mix the following and scatter in trunks and bags containing furs and woolens: ½ lb. Carpet Cleaner Whether you rent a machine or have a cleaning service, don’t use the carpet shampoo they want to sell, even if they “guarantee” that it is all natural and safe. Instead add these to a bucket (about four gallons) of water and use it as the cleaning solution: Wash water Rinse water 1/3 cup borax ¼ cup grain alcohol 2 tsp. If you are just making one pass on your carpet, use the borax, alcohol, and boric acid. Your largest enamel or ceramic (not stainless steel, not aluminum) cooking pot, preferably at least 10 quarts Black walnuts, in the hull, each one still at least 50% green, enough to fill the pot to the top Grain alcohol, about 50% strength, enough to cover the walnuts ½ tsp. The walnut is inside, but we will use the whole ball, uncracked, since the active ingredient is in the green outer hull. Pour into glass jars or bottles, discarding walnuts, and divide the remaining vitamin C amongst the jars. If the glass jar has a metal lid, first put plastic wrap over the top before screwing on the lid. It is stronger than the concentrate made with just a few black walnuts in a quart jar (my earlier recipe), because there are more walnuts per unit liquid. In addition, you will not dilute it before use (although when you take it, it will usually be in water). If you are not going to use all of them in this batch, you may freeze them in a resealable plastic bag. To reduce air exposure, fill the pot as much as possible, without touching the plastic wrap, while still keeping a snug fitting lid. Even more importantly, the glass jars or bottles you use to store your tincture should have as little air space as possible, without touching the plastic wrap on top. The idea is not to have partial jars, with a lot of air space, sitting for longer than a month or so. Black Walnut Hull Tincture (Regular Strength) This is the potency I used originally. The Extra Strength recipe is four times as potent as the original recipe, so it must be diluted in quarters. Yet another method is to buy vodka that is 100 proof (50% alcohol) and mix one part vodka with four parts water. Black Walnut Hull Extract (Water Based) Because you do not know how commercially available ex- tracts were made, and may not be able to test for solvent pollu- tion, it is wisest to make it yourself! This recipe is intended for alcoholic persons: cover the green balls in the 10 quart (non-metal) pot with cold tap water. For use: in programs calling for Extra Strength Black Walnut Hull Tincture use four times as much of this water based recipe (8 tsp. Important Note: do not use bottled or purchased water to make this tincture or you could pollute it with benzene! Emmenagogue (Menstrual Period Inducer) Here are four herbs that can each bring on your period. They can be started anytime but the most-effective time is before your next calculated period time (count days as if you never missed a period).
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