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Salernitan anatomical writers did de- vote considerable attention to the anatomy of the uterus and the ‘‘female tes- ticles’’ trimethoprim 960 mg; that these descriptions became increasingly more detailed over time owes not to inspection of women’s bodies generic 960 mg trimethoprim free shipping, however 480mg trimethoprim visa, but to the assimilation of bits and pieces of anatomical and physiological lore from a variety of other written sources. Nicholaus, the author of the most important text on compound medicines, promised his readers that by dispensing the medicines described in his text, ‘‘they would have an abundance of money and be glorified by a multitude of friends. These men began to style themselves as ‘‘healer and physician’’ (medicus et physicus) and later simply as ‘‘physician. Yet even as cer- tain practitioners were able to enhance their social status through their learn- ing, there continued to exist in Salerno traditions of medical practice that par- took little or not at all in the new learned discourses. It is clear that religious and even magical cures continued to coexist alongside the rationalized prac- tices of physical medicine. There were, moreover, as we shall see in more detail later, some women in Salerno who likewise engaged in medical practice; these women apparently could not avail themselves of the same educational privi- leges as men and are unlikely to have been ‘‘professionalized’’ in the same way as their male counterparts. There was, in any case, no regulation of medical practice in this period (licensing was still a thing of the future),59 so to that degree the ‘‘medical marketplace’’ was open. The context in which the three Salernitan texts on women’s medicine came into being thus was quite expansive and open to a variety of influences and practices. These texts share to varying degrees the characteristics of ‘‘main- stream’’ Salernitan medical writings, Conditions of Women with its attempts to assimilate Arabic medicine, Treatments for Women with its collection of tra- ditional local practices. Women’s Cosmetics is most interesting as an example of how traditional empirical practices could be adopted by learned physicians and deployed as another strategy in re-creating the ideal of the ancient city physician whose success lay largely in the reputation he was able to cultivate. Clearly, women were among the patients whose patronage these practitioners wanted to earn. The Lombard princess Sichelgaita seems to have had her own personal physician, Peter Borda, in the s,60 and there is ample evidence that women regularly figured in the clientele of male practitioners. Neverthe- less, as was noted above, gynecology and obstetrics were areas of medical prac- tice that saw relatively little innovation by male medical writers. Male physi- cians clearly diagnosed and prescribed for gynecological conditions, and they  Introduction recommended a wide variety of potions and herbs for difficult birth. But it is doubtful that they ever directly touched the genitalia of their female patients. This limitation of male gynecological and obstetrical practice left room for the existence of female practitioners whose access to the female body was less restricted. As we have seen, women had no higher social position here and they may well have been less literate than women in neighboring areas. Few specialized texts on women’s medicine existed in Arabic, and nonewere translated by Constantine. The larger intellectual currents of Salernitan medicine—the concern to system- atically analyze and explain, the eagerness to incorporate new pharmaceutical products, and, most important, the desire to capture all this new knowledge in writing—provided the spark that would make Salernitan women’s medicine different from anything that had gone before it. Women’s Medicine P-S G Had it been possible to draw up an inventory of European medical writings on women in the third quarter of the eleventh century, that list would have included at least two dozen different texts. But such an inventory would be insufficient to assess the varying im- Introduction  portance of these texts, for even though copies might be found in this library or that, an individual text’s usefulness may have been minimal, either because its Latin (often interlarded with Greek terminology) had been corrupted over the course of several centuries of copying or because its theoretical precepts were no longer adhered to or even understood. The gynecological literature in western Europe prior to the late eleventh century represented two ancient medical traditions. First was the Hippocratic tradition, embodied in a corpus of anonymous Greek writings composed be- tween the fifth and fourth centuries . The gynecologi- cal materials of the Hippocratic Corpus constituted as much as one-fifth of that vast collection of writings. The abbreviated translation of Diseases of Women  laid out the basic physiology of women (especially as it related to pregnancy), then moved on to alterations of the womb, impedi- ments to conception, disorders of gestation, causes of miscarriage, difficulties of birth, and subsequent problems. The longer version, called by its modern editor On the Diverse Afflictions of Women, addresses questions of etiology, diagnosis, and prognosis, as well as the more routine matters of basic pathology and ther- apy in its ninety-one subheadings. Three other texts (Book on the Afflictions of Women, Book on the Female Affliction, and Book on Womanly Matters) also derive from Diseases of Women ; these are fairly brief and often redundant recipe col- lections rather than organized medical treatises. Just as influential in dissemi- nating Hippocratic views of the female body were the Aphorisms, a collection of pithy verities about the nature of the physician’s craft, the symptoms of dis- ease, prognostic signs, and so forth. The fifth (or in some versions the sixth) of the seven sections of the Aphorisms was devoted primarily to women and their diseases; it was on occasion accompanied by an extensive commentary. Here, a reader would find such statements as ‘‘If the menses are deficient, it is a good thing when blood flows from the nostrils,’’ or ‘‘If in a woman who is pregnant the breast suddenly dries up, she will abort. Soranus of Ephesus, a Greek physician from Asia Minor who practiced in Rome in the late first and early second century . All the physician needed to know was that therewere three basic states of the human body: the lax, the con- stricted, and a combination of the two. Upon diagnosing which of the three states was manifest in any given case, the physician’s therapeutic response was to treat by opposites: to relax the constricted, constrict the lax, and do both in mixed cases, treating the more severe symptoms first. Soranus’s views of female physiology and pathology in particular seem to have been novel.

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The tu- by features of mitral stenosis with variable cardiac mur- mour tends to grow upwards towards the skull base generic trimethoprim 960mg visa. Thromboembolism may result from the abnor- Patients present with a pulsatile swelling in the upper mal flow pattern through the atrium safe trimethoprim 960mg. It occurs in 40% neck at the medial border of the sternocleidomastoid and is a common presenting feature purchase trimethoprim 960mg overnight delivery. Classically on palpation the lump is mobile from side to side but not up and down, and there may be an associated overlying carotid bruit. Echocardiography demonstrates common metastatic lymph node from a head and neck the mass lesion within the atrium. Macroscopy The tumour is usually a polypoid mass on a stalk, its sur- Microscopy face covered with thrombus. It is composed of is made up of connective tissue, with a variety of cell chief cells with clear cytoplasm and a round nucleus en- typessurrounded by extracellular matrix. Investigations Management Angiography shows a splaying of the carotid bifurcation The tumour is surgically removed under cardiopul- (lyre sign). Management Prognosis Surgical excision may be performed especially in young Five per cent local recurrence within 5 years. Inelderlypatientssurgicalremovalmay up with regular echocardiography is therefore indicated not be necessary. Patients may complain of breathlessness, dif- ficulty in ‘catching their breath’, a feeling of suffocation, Cough and sputum or tightness in the chest. Dyspnoea should be graded by the exertional capability of the patient and the impact Acough is one of the most common presentations of on their lifestyle. In general dyspnoea arises from either the respira- The most common patterns are shown in Table 3. It is usu- thopnoea and paroxysmal nocturnal dyspnoea suggests ally streaky, rusty coloured and mixed with sputum. It a cardiovascular cause, patients with lung disease may should be distinguished from haematemesis (vomiting experience orthopnoea due to abdominal contents re- of blood) which may appear bright red or like coffee stricting the movement of the diaphragm. For diagnosis, respiratory dyspnoea is best considered 1 The most common cause is acute infection, particu- according to the speed of onset and further differenti- larly with underlying chronic obstructive airways dis- ated by a detailed history and clinical examination (see ease. Wheeze and stridor 3 Pulmonary oedema in cardiac failure causes pink, frothy sputum and pulmonary infarction such as pul- Wheeze and stridor are respiratory sounds caused by air- monary embolism may cause haemoptysis. Massive haemoptysis may be caused by bronchiectasis, Awheeze is described according to where it is best bronchial carcinoma or tuberculosis. Recent Smoker, weight Haemoptysis Carcinoma until proved (weeks) loss, occasionally otherwise (often dull chest pain associated pneumonia) specific size of airway – usually one bronchus) or poly- creased airway pressure opens the valve, so expiratory phonic (widespread airway limitation). Othercauses inhalation, acute epiglottitis (drooling, unwell), ana- include chronic obstructive airways disease and acute phylaxis, inhaled foreign body. It occurs airway (larynx, pharynx or trachea), extrinsic com- because in inspiration, a valve-like effect worsens ob- pression (lymph nodes, retrosternal thyroid), bilateral struction in the major airways. Pulmonary oedema Cardiac history, intermittent (exertional, orthopnoea, paroxysmal nocturnal dyspnoea) or acute – basal crackles, frothy sputum, cardiac chest pain Extrinsic allergic alveolitis Recurrent, occupational exposure Days/weeks Pleural effusions Dull to percussion, reduced breath sounds Carcinoma of the bronchus/ Obstruction causes collapse and consolidation of lung. Months/years Chronic bronchitis/emphysema Smoking history, cough & sputum Idiopathic pulmonary fibrosis Clubbing and cyanosis, fine crackles Occupational fibrotic lung disease Occupational history 92 Chapter 3: Respiratory system Respiratory chest pain with abdominal pain, e. Chest pain can arise from the cardiovascular system, the respiratory system, the oesophagus or the musculoskele- talsystem. Respiratorychestpainisusuallyverydifferent Signs fromischaemicchestpain,asitischaracteristicallysharp, and worse on inspiration. Clubbing On enquiring about chest pain ask about the site, nature (sharp, burning, tearing), radiation, precipitat- Clubbing is an increased amount of soft tissue in the ing/relieving factors (deep inspiration, coughing, move- terminal phalanx of the fingers and toes, concentrated ment) and any associated symptoms such as dyspnoea. It is caused by inflamed pleural pathological mechanism of clubbing is unknown, and surfaces rubbing on one another. Pleurisy may also be caused by connective tissue diseases such as rheumatoid Normal breath sounds are caused by the turbulent flow arthritis. They are Chest wall pain may be easily confused with pleuritic transmitted to the chest wall through the lungs (see pain, as it is often sharp, but it can be reproduced by Table 3. Other Bronchiectasis causes include thoracic herpes zoster – a persistent pain, Lung abscess which may be burning and last several days before the Chronic empyema Pulmonary fibrosis rash appears. Idiopathic pulmonary fibrosis Retrosternal pain may be due to tracheitis or medi- Cystic fibrosis astinal disease (lymphoma, mediastinitis) but is more Asbestosis commonly cardiac. Cardiovascular Cyanotic congenital heart disease Infective endocarditis Gastrointestinal Cirrhosis, especially primary biliary Non-respiratory chest pain cirrhosis Central chest pain, particularly if radiating to the neck Inflammatory bowel disease Coeliac disease or arms, is more likely to be cardiac. Pericarditis causes Idiopathic Familial usually before puberty a sharp retrosternal/precordial pain which may mimic Idiopathic pleuritic pain as it may be exacerbated by deep inspira- Rare Thyroid acropachy tion, but is classically relieved by leaning forwards. Pain Pregnancy at the shoulder tip is often referred pain from the di- Unilateral clubbing Bronchial arteriovenous aneurysm aphragm, and may reflect an abdominal cause such as Axillary artery aneurysm cholecystitis. Equally, respiratory disease may manifest Chapter 3: Respiratory procedures 93 Table3. Inspiration is However, theseconditionsmayoccurwithoutwheeze, slightly louder and longer than despite severe obstruction.

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Miles (1992) tested the effects of daily ingestion of 64 g or 34 g of Dietary Fiber for 10 weeks in healthy adult males cheap trimethoprim 480mg online. The ingestion of 64 g/d of Dietary Fiber resulted in a reduction in protein utilization from 89 purchase trimethoprim 480 mg online. Because most individuals consuming high amounts of fiber would also be consuming high amounts of energy trimethoprim 960mg with visa, the slight depression in energy utilization is not significant (Miles, 1992). In other studies, ingestion of high amounts of fruit, vegetable, and cereal fiber (48. Again, however, the Dietary Fiber intakes were very high, and because the recommendation for Total Fiber intake is related to energy intake, the high fiber consumers would also be high energy consumers. Increased consumption of added sugars can result in decreased intakes of certain micronutrients (Table 11-5). This can occur because of the abundance of added sugars in energy-dense, nutrient-poor foods, whereas naturally occurring sugars are primarily found in fruits, milk, and dairy products that also contain essential micro- nutrients. The sample (n = 14,704) was divided into three groups based on the percentage of energy consumed from added sugars: (1) less than 10 percent of total energy (n = 5,058), (2) 10 to 18 percent of total energy (n = 4,488), and (3) greater than 18 percent of total energy (n = 5,158). In addition, the high sugar consumers (Group 3) had lower intakes of grains, fruits, vegetables, meat, poultry, and fish com- pared with Groups 1 and 2. At the same time, Group 3 consumed more soft drinks, fruit drinks, punches, ades, cakes, cookies, grain-based pastries, milk desserts, and candies. Similar trends were also reported by Bolton- Smith and Woodward (1995) and Forshee and Storey (2001), but were not observed by Lewis and coworkers (1992). Emmett and Heaton (1995) reported an overall deterioration in the quality of the diet in heavy users of added sugars. Others have shown that intakes of soft drinks are negatively related to intakes of milk (Guenther, 1986; Harnack et al. Because not all micronutrients and other nutrients, such as fiber, were evaluated, it is not known what the association is between added sugars and these nutrients. While the trends are not consistent for all age groups, reduced intakes of calcium, vitamin A, iron, and zinc were observed with increasing intakes of added sugars, particularly at intake levels exceeding 25 percent of energy. Although this approach has limitations, it gives guidance for the planning of healthy diets. In one large dietary survey, linear reductions were observed for certain micronutrients when total sugars intakes increased (Bolton-Smith and Woodward, 1995), whereas no consistent reductions were observed in another survey (Gibney et al. Bolton- Smith (1996) reviewed the literature on the relation of sugars intake to micronutrient adequacy and concluded that, provided consumption of sugars is not excessive (defined as less than 20 percent of total energy intake), no health risks are likely to ensue due to micronutrient inadequacies. High Fat, Low Carbohydrate Diets of Adults Risk of Obesity Epidemiological Evidence. In some countries, low fat, high carbohydrate diets are asso- ciated with a low prevalence of obesity, whereas in others they are not. Many case-control and prospective studies failed to find a strong correlation between percent of energy intake from fat and body weight (Heitmann et al. One statistically well-designed study that included direct measurements of body fat and considered potentially confounding factors such as exercise concluded that total dietary fat was positively cor- related with fat mass (adjusted for fat-free mass, r = 0. Most multiple regression studies found that about 3 percent of the total variance in body fatness was explained by diet, though some studies placed the estimate at 7 to 8 percent (Westerterp et al. Longitudinal studies generally supported dietary fat as a predic- tive factor in the development of obesity (Lissner and Heitmann, 1995). However, bias in subject participation, retention, and underreporting of intake may limit the power of these epidemiological studies to assess the relationship between dietary fat and obesity or weight gain (Lissner et al. Another line of evidence often cited to indicate that dietary fat is not an important contributor to obesity is that although there has been a reduction in the percent of energy from fat consumed in the United States, there has been an increase in energy intake and a marked gain in average weight (Willett, 1998). Survey data showed an increase in total energy intake over this period (McDowell et al. Another study that used food supply data showed that fat intake may indeed be rising in the United States (Harnack et al. Several mechanisms have been proposed whereby high fat intakes could lead to excess body accumulation of fat. Foods containing high amounts of fat tend to be energy dense, and the fat is a major contributor to the excess energy con- sumed by persons who are overweight or obese (Prentice, 2001). The energy density of a food can be defined as the amount of metabolizable energy per unit weight or volume (Yao and Roberts, 2001); water and fat are the main determinants of dietary energy density. Energy density is an issue of interest to the extent that it influences energy intake and thus plays a role in energy regulation, weight maintenance, and the subsequent development of obesity. Three theoretical mechanisms have been identified by which dietary energy density may affect total energy intake and hence energy regulation (Yao and Roberts, 2001). Some studies suggest that, at least in the short- term, individuals tend to eat in order to maintain a constant volume of food intake because stomach distension triggers vagal signals of fullness (Duncan et al. Thus, consumption of high energy-dense foods could lead to excess energy intake due to the high energy density to small food volume ratio.

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