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By G. Owen. Loyola College, Baltimore.

Hence when some twenty years later a debate over the author’s gender and identity was initiated (and it has continued to the present day) purchase rogaine 5 60 ml on line, it was assumed that there was only one author involved buy discount rogaine 5 60 ml line. What can they reveal about the impact of the new Arabic medicine that began to infiltrate Europe in the late eleventh century? Is there order rogaine 5 60 ml without a prescription, in fact discount rogaine 5 60 ml with mastercard, a female author behind any of the texts and, if so, what can she tell us about medieval women’s own views of their bodies and the social circumstances of women’s healthcare either in Salerno or elsewhere in Europe? Answering these questions calls for close textual analysis that pulls apart, layer by layer, decades of accretion and alteration. Such analysis shows us not simply that there are three core texts at the heart of the Trotula but also that the ensemble became a magnet for bits and pieces of material from entirely unrelated sources. We cannot, for example, attribute the neonatal procedures described in ¶¶– to local southern Italian medical practices but must rec- ognize them instead as the work of a ninth-century Persian physician named Rhazes. Such analysis shows us, in other words, that the Trotula ensemble is a patchwork of sources. There is, consequently, no single (or simple) story to be told of ‘‘Trotula’’ or women’s medicine at Salerno. Knowledge of the multiplicity of the Trotula may resolve certain ques- tions (about the redundancies and inconsistencies that so troubled the Renais- sance editor Georg Kraut, for example), but it raises others. Particularly, if the texts are so protean (a total of fifteen different versions of the independent texts and the ensemble can be identified in the medieval manuscripts),8 howdowe choose any single version to study? Obviously, the authors of the three origi- nal, independent works had their own unique conceptions of the content and intended uses of their texts. On the basis of my reconstructions of these origi- nal forms of the texts, I describe in the Introduction their more distinctive medical theories and practices; I also summarize what is now known about the medical practices of the women of Salerno—including, most important, Trota. Nevertheless, the three original twelfth-century works often bore only an oblique resemblance to the text(s) that later medieval readers would have had in front of them. The Trotula ensemble, ragged patchwork though it is, has a historical importance in its own right, since it was this version of the texts that the largest proportion of medieval readers would have seen, and it was this assembly of theories and remedies (whatever their sources or however incon- xiv Preface gruous the combination originally may have been) that would have been most commonly understood throughout later medieval Europe as the authoritative Salernitan teachings on women and their diseases. One of the several versions of the ensemble was particularly stable in form and widespread in circulation: this is what I have called the ‘‘standardized en- semble,’’ which, with twenty-nine extant copies, ranks as the most popular ver- sion of the Salernitan texts in any form, circulating either independently or as a group. The standardized ensemble is a product of the mid-thirteenth cen- tury (whether it was produced at Salerno itself I cannot say) and it reflects the endpoint of what had been an active first century of development for the three texts. I have based the present edition on the earliest known complete copy of the standardized ensemble, an Italian manu- script from the second half of the thirteenth century, and I have collated it in full with eight other manuscripts coming from various parts of Europe and dating from the later thirteenth century through the turn of the fourteenth century. The edition and translation presented here, then, reflect the standardized Trotula ensemble text as it was known and used up through about . To facilitate a historically nuanced understanding of the ensemble, I have anno- tated the edition to highlight its major points of divergence from the three original Salernitan texts on women’s medicine. Inevitably, many nuances— anatomical, nosological, and botanical—can never be adequately recaptured. Many more questions remain regarding Trota and the Trotula, but it is my hope that this first edition of these important and influen- tial texts will offer a foundation for future debates and, in the process, enhance our understanding of women’s healthcare in medieval Europe. For complete descriptions of the manuscripts, please see my pub- lished handlists. Since many passages from the original texts were moved or deleted during the first century of the texts’ development, however, I have also employed subordinate alphanumerics so that readers may understand where these now-lost sections were located. So, for example, ¶f, a detailed proce- dure for vaginal hygiene, had appeared in early versions of Women’s Cosmetics in the position after ¶ as found in this edition. Readers may refer to the concordances of the Trotula texts in my above-mentioned essay for full com- parisons of all the different versions of the texts. As noted ear- lier, the gender of the author(s) of the Trotula has been a central concern in scholarship to date and will, no doubt, be of prime interest to many readers of the present edition precisely because gender—whether of the authors, scribes, practitioners, or patients—is central to larger historical questions surrounding women’s healthcare and roles in medical practice. Although it is not my objec- tive to settle all these questions here, I have employed gendered pronouns to indicate where I think the gender of the author (or, for that matter, the patient) is clear and where it is not.

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Bans on advertising of tobacco products in public places and on sales of tobacco to young people are essential components of any primary prevention programme addressing noncommunicable diseases (140) order rogaine 5 60 ml overnight delivery. The cholesterol-raising properties of saturated fats are attributed to lauric acid (12:0) rogaine 5 60 ml sale, myristic acid (14:0) rogaine 5 60 ml for sale, and palmitic acid (16:0) rogaine 5 60 ml fast delivery. Stearic acid (18:0) and saturated fatty acids with fewer than 12 carbon atoms are thought not to raise serum cholesterol concentrations (146, 147). The effects of different saturated fatty acids on the distribution of cholesterol over the various lipoproteins are not well known. Trans-fatty acids come from both animal and vegetable sources and are produced by partial hydro- genation of unsaturated oils. Metabolic and epidemiological studies have indicated that trans-fatty acids increase the risk of coronary heart disease (145, 152, 153). It has also been demonstrated that replacing saturated and trans-unsaturated fats with monounsaturated and polyunsaturated fats is more effective in preventing coronary heart disease events than reducing overall fat intake (145, 153, 155). Current guidelines recommend a diet that provides less than 30% of calories from dietary fat, less than 10% of calories from saturated fats, up to 10% from polyunsaturated fats, and about 15% from monounsaturated fats (86, 88, 148). Metabolic studies have shown that dietary cholesterol is a determinant of serum cholesterol concentration (156–158). Reducing dietary cholesterol by 100 mg a day appears to reduce serum cholesterol by about 1% (147). However, there is marked individual variation in the way serum cholesterol responds to dietary cholesterol (159); dietary cholesterol seems to have a relatively small effect on serum lipids, compared with dietary saturated and trans-fatty acids (88, 104, 158). Studies have demonstrated that, in controlled conditions, it is possible to modify behaviour, but in daily life the required intensity of supervision may not be practicable. The effects of advice about reducing or modifying dietary fat intake on total and cardiovascular mortality and cardiovascular morbidity in real-life settings were assessed in a systematic review of 27 studies, comprising 30 902 person–years of observation (160). The interventions included both direct provision of food and, in most trials, dietary advice to reduce intake of total fat or saturated fat or dietary cholesterol, or to shift from saturated to unsaturated fat. The pooled results indicate that reducing or modifying dietary fat reduces the incidence of combined cardiovascular events by 16% (rate ratio 0. The reduction in cardiovascu- lar mortality and morbidity was more pronounced in trials lasting at least 2 years. The protective effect of polyunsaturated fats is similar in high- and low-risk groups for both sources (seafood and plants), and in women and men (104, 155, 161, 162). Epidemiological studies and clinical trials suggest that people at risk of coronary heart disease benefit from consuming omega-3 fatty acids (104, 161, 163, 164). The proposed mechanisms for a cardioprotective role include altered lipid profile, reduced thrombotic tendency, and antihypertensive, anti-inflammatory and antiarrhythmic effects (165–168). A systematic review showed a significant benefit of fish-based dietary supplemental omega-3 fatty acids on cardiovascular morbidity and mortality in patients with coronary heart disease (169, 170). Cohort studies analysing omega-3 fatty acid intake and risk of cardiovascular diseases have shown inconsistent findings, however, and a recent large trial of omega-3 fatty acids did not find any benefits (171). In an attempt to clarify their role, an updated meta-analysis has also been conducted (170, 172). Using data from 48 randomized controlled trials and 41 cohort analyses, an assessment was made of whether dietary or supplemental omega-3 fatty acids altered total mortality, cardiovas- cular events or cancers. Pooled trial results did not show a reduction in the total mortality risk or the risk of combined cardiovascular events in those taking additional omega-3 fats. Population studies have demonstrated that high salt intake is associated with an increased risk of high blood pressure (173). Several observational studies have linked baseline sodium intake, estimated from either 24-hour urinary sodium excretion or dietary intake, to morbidity and mor- tality. In a Finnish study, the hazard ratios for coronary heart disease, cardiovascular disease, and all-cause mortality, associated with a 100 mmol increase in 24-h urinary sodium excretion in men and women, were estimated as 1. A prospective study in a Japanese cohort also showed that high dietary salt intake increased the risk of death from stroke (175). A study in hypertensive patients reported an inverse relation between sodium intake and cardiovascular outcomes (176) and suggested a J-curve relationship. This discordant finding has been attributed to methodologi- cal limitations and further study is needed. The efficacy of reduced sodium intake in lowering blood pressure is well established (176, 177).

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Skin flaps Geography Mayoccur anywhere cheap rogaine 5 60 ml line, but higher incidence in urban Skin flaps differ from skin grafts in that they are taken areas cheap rogaine 5 60 ml with mastercard. The coverage can thus be thicker and stronger than grafts buy 60 ml rogaine 5 with visa, and can be applied to avascularareassuchasexposedbone discount 60 ml rogaine 5 with amex,tendonsandjoints. Aetiology/pathophysiology Flaps may be transferred whilst maintaining their orig- The term atopy is a disease resulting from allergic inal vascular attachments (pedicle flaps), or may be re- sensitisation to normal environmental constituents anastamosed to local blood supply (free flaps). The underly- ing cause and mechanisms in eczema have yet to be fully elucidated; however, dry skin (xerosis) is an important Scaly lesions contributor. There appear to be genetic and immuno- logical components to allergic sensitisation (see also page 498). Offspring of one atopic parent have a 30% risk of Atopic eczema being atopic, which rises to 60% if both parents are Definition atopic. Achronic inflammatory skin disorder associated with r Chromosome studies suggest that atopic tendency atopy, causing dry, scaly, itchy lesions. More common in children with peak onset usually 2–18 Serum IgE is elevated in 85% of individuals and higher months. It is thought that the high frequency of secondary Sex infectionisacombinationofthelossofskinintegrityand M = F deficiency of local antimicrobial proteins. These are erythematous and r Antibiotics are used for secondary bacterial infection. Lesionsmayweepand r Wetwraps consist of the application of topical agents have tender tiny blisters termed vesicles especially when under bandages to facilitate absorption. The distribution is age depen- may be administered in this way or coal tar may be dent: used as a keratolytic in lichenified skin. If steroids are r Babies develop eczema predominantly on the face and appliedunderwetwrapsthedose/potencymustbede- head; this may resolve or progress by 18 months to the creased as increased absorption may result in systemic childhood/adult pattern. Complications r Topical tacrolimus, an immunosuppressant, is being Staphylococcus aureus is found on the skin of 90%, which increasingly used in children prior to the use of high- may result in acute infection (impetigenised eczema). Itappearssafeandeffective;however, Primary infection with herpes simplex may give a very the long-term risks are unknown, as it is a relatively severe reaction known as eczema herpeticum, which in new preparation. Pimecrolimus is under study as a the young may cause dehydration and is life-threatening. Prognosis Eczemahasafluctuatingcoursewithapproximately50% Management resolving by 18 months, and few have problems beyond There is no curative treatment. In ba- bies it may be appropriate to either test for cow’s milk allergy or to perform a therapeutic trial with a cow’s Contact dermatitis milk protein free formula. Definition r Generalised dry skin (xerosis) requires regular fre- Contact dermatitis is an allergic or irritant-induced der- quent use of emollient moisturisers especially af- matitis arising from direct skin exposure to a substance. Cream preparations are water based with emulsifiers and preservatives and they tend Age todrytheskin. A balance has to be struck between application of sufficient grease and cosmetic satisfaction. Geography The lowest potency that is effective should be used Exposure is most common in the home or industrially and higher potency reserved for resistant cases. Chapter 9: Scaly lesions 387 Aetiology/pathophysiology commonest areas affected are the eyebrows and around r Irritant contact dermatitis (80%) is caused by over- the eyes extending into the scalp. In babies a Oncetheepidermalbarrierisdamagedasecondaryin- widespread lesion of the scalp (cradle cap) is seen, and flammatory response occurs. Psoriasis Definition Clinical features Psoriasisisachronic,non-infectious,inflammatorycon- Contact dermatitis often affects the hands or face. Le- dition of the skin, characterised by well-demarcated ery- sions may also affect the legs of patients with chronic thematous patches and silvery scaly plaques. Management Age The allergens can be identified by patch testing (see page Peak of onset in teens and early 20s and late onset 55–60 467) and avoided. Seborrhoeic The aetiology is not fully understood but genetic en- dermatitis is a chronic scaly inflammatory eruption af- vironmental and immunological components are sug- fecting areas rich in sebaceous glands. There is concor- rum ovale,ayeast that colonises the skin of patients with dance in monozygotic twins and a suggestion of genes seborrhoeic dermatitis; however, it is unclear if this is the located within the major histocompatibility complex cause or effect of the condition. The lesions appear pinkish due to mild erythema and r There is a suggestion of environmental components. The Group A streptococcal sore throat can lead to guttate 388 Chapter 9: Dermatology and soft tissues psoriasis, psoriatic lesions occur at sites of trauma a thin or absent granular layer.

Even when meat is the dominant food rogaine 5 60 ml otc, diets of a wide range of populations do not usually contain more than about 40 percent of energy as protein (Speth purchase rogaine 5 60 ml fast delivery, 1989) cheap 60 ml rogaine 5 mastercard. Indeed buy 60 ml rogaine 5 with amex, Eskimos, when eating only meat, maintain a protein intake below 50 percent of energy by eating fat; protein intake estimated from data collected in 1855 was estimated to be about 44 percent (Krogh and Krogh, 1913). Two arctic explorers, Stefansson and Andersen, ate only meat for a whole year while living in New York City (Lieb, 1929; McClellan and Du Bois, 1930; McClellan et al. For most of the period, the diet contained 15 to 25 percent of energy as protein, with fat (75 to 85 percent) and carbohydrate (1 to 2 percent) providing the rest, and no ill effects were observed (McClellan and Du Bois, 1930). However, consumption of greater portions of lean meat (45 percent of calories from protein) by one of the two explorers led rapidly to the development of weakness, nausea, and diarrhea, which was resolved when the dietary protein content was reduced to 20 to 25 percent of calories (McClellan and Du Bois, 1930). If continued, a diet too high in protein results in death after several weeks, a condition known as “rabbit starvation” by early American explorers, as rabbit meat contains very little fat (Speth and Spielmann, 1983; Stefansson, 1944a). Similar symptoms of eating only lean meat were described by Lewis and Clark (McGilvery, 1983). Conversely, an all-meat diet with a protein content between 20 and 35 percent has been reported in explorers, trappers, and hunters during the winters in northern America surviving exclusively on pemmican for extended periods with no adverse effects (McGilvery, 1983; Speth, 1989; Stefansson, 1944b). Pemmican is a concentrated food made by taking lean dried meat that has been pounded finely and then blending it with melted fat. It contains about 20 to 35 percent protein; the remainder is fat (Stefansson, 1944b). Nitrogen balance studies at protein intakes of 212 to 300 g/d consistently have shown positive nitrogen balance (Fisher et al. In particular, no negative nitrogen balances were reported, suggesting that the high protein intake had no detrimental effect on protein homeostasis. Rudman and coworkers (1973) studied the effect of meals containing graded levels of protein on the rate of urea production by human liver in vivo. At higher intakes, the rate was not increased further, but the maximum rate continued longer. In a 70-kg sedentary person, this maximum rate corresponds to about 250 g/d of protein, or about 40 percent of energy. The correspondence of this maximum to the apparent upper level of protein intake (45 percent of energy) described in the earlier section related to the experiences reported by explorers has therefore been suggested as cause and effect (Cordain et al. How- ever, this interpretation should be made with caution, as there was no period of adaptation to the meal in the study of Rudman’s group (1973). It is probable that when high protein diets are given, the capacities to oxidize amino acids and synthesize urea are increased, as has been demon- strated in animals (Das and Waterlow, 1974). High protein intakes have also been implicated in chronic diseases such as osteoporosis, renal stones, renal insufficiency, cancer, coronary artery disease, and obesity (see “High Protein Diets” in Chapter 11). However, the current state of the literature does not permit any recommendation of the upper level for protein to be made on the basis of chronic disease risk. Because of the current widespread use of protein supplements, more research is needed to assess the safety of high protein intakes from supplements; until such information is avail- able, caution is warranted. The potential implications of high dietary protein for bone and kidney stone metabolism are not sufficiently clear at present to make recommen- dations for the general population to restrict their protein intake. This life stage group also had the highest reported protein intake at the 99th percentile of intake at 190 g/d, or 2. Risk Characterization The risk of adverse effects resulting from excess intakes of protein from foods appears to be very low at the highest intake noted above. Women over the age of 50 had the highest reported percentage of total energy from protein at the 99th percentile of 23. Because the data on adverse effects resulting from high protein intakes are limited, caution may be warranted. Therefore, atten- tion was focused on intakes of amino acids from dietary supplements and when utilized as food ingredients, such as monosodium glutamate in food or aspartic acid and phenylalanine in aspartame. Pharmacokinetic studies were sought to bridge potential differences between animals and humans.

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