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Vice Chair, University of Cincinnati College of Medicine

Thus Isabel begins by imagining that she need not marry and then demonstrates that medicine rock buy generic mildronate 250mg line, like Catherine Sloper medications requiring prior authorization generic 250mg mildronate free shipping, her ``ridiculous' imagination gives her no sound basis for selecting a husband medications 7 buy mildronate toronto. Osmond ­ he was a specimen apart medications for ibs generic 500mg mildronate mastercard,' she unsuspectingly entered the ``steel trap' of marriage to the self-interested Osmond, and their single child died. Then, sealing her fate, Isabel exhibits a final trait of the Spencerian female whose ``admiration for power' makes her ``religiously excitable' and susceptible to ``transcendent force. In these novels by both men and women, the question was whether women should have access to higher education (much less the vote) and, relatedly, whether women are fit, from the evolutionary point of view, to be doctors. Clarke had argued in Sex in Education; or, A Fair Chance for the Girls (1873) that it was unfair and unnatural to subject girls to the rigors of higher education at the time when their ovaries were developing. Because their energies were necessarily devoted primarily to their reproductive functions, resulting in their brains being smaller and more delicate, they Darwin, Science, and Narrative 387 would suffer psychological stress and damage to their reproductive health. Grace is ``too nervous'; both she and her mother declare her unfit for such work, and, to make things worse, her single patient, a woman friend, abandons her in order to be treated by ``a man doctor! Zay is a strong and competent ``woman of science' whose main problem in life is how to fend off the advances of Waldo Yorke, the hero. Zay, suggests that the Descent of Man is not the last word in evolution and that the ``new woman' is not only fit for the mental work of science, but aspires, plant-like, to a higher light. Sarah Orne Jewett presented yet another view of the female doctor in A Country Doctor (1884), wherein she portrays the heroine Nan Prince as belonging to a ``class of women who are the result of natural progression and variation. Prance, a minor character in the novel, is certainly an accomplished woman of science. But, according to his witty and wicked design, James suggests that the price of Dr. Clarke and Howells would have predicted, for this ``dry little woman' ``looked like a boy. The 1890s: Environment, Heredity, Sexual Selection, and Evolutionary Psychology By the early 1890s the gravity of evolutionary thought had intensified, and novelists began to address a greater range of evolutionary problems. The intensifying interest in evolutionary thought between the 1870s and 1890s is also evident in the career of Mark Twain, who began reading science (The Descent of Man, for example) in the 1870s, but in those early years was ``ambivalent about science' or comically distanced from it (Cummings 1988: 15). By 1894, when Frank Norris began work on Vandover and the Brute (posthumously published in 1914) and McTeague (1899), he had already studied evolutionary biology under Joseph Le Conte at the University of California. Working also with the theory of sexual selection in the lives of these characters, he suggested that neither had evolved a capacity for ``love. In McTeague, for example, the child born to the ``Polish Jew' Zerkow and the Mexican woman Maria Macapa is a shortlived ``strange hybrid little being,' and because Norris views the parents as almost subhuman, they can neither love the child nor even be moved by its death. Thus Edna Pontellier doubts whether a civilized woman would ``select' according to wealth and social position, as Darwin had theorized. Instead, Edna feels sexual antipathy for her husband and selects two lovers, one to satisfy her sexual needs and another because she is attracted to his physical beauty. Although she is a loving mother, she cannot be fulfilled in that way alone, and she hears from Dr. Mandelet that the illusion of sexual love is a ``provision of Nature; a decoy to secure mothers for the race. The Awakening is only one of many novels during these years to explore the darkness and violence of sexual ``love. In the end Frederic suggests that Theron is ``damned' not in a theological but in the evolutionary sense ­ because he is a weak man, intellectually, and because he is a complete failure in ``the work of selection. Du Bois wrote in 1903 that ``the problem of the Twentieth Century is the problem of the color-line' (Du Bois 1986: 359). Thus in the Health and Physique of the Negro American Du Bois refuted the claims of scientists and writers such as Le Conte and Norris or Thomas Dixon, Jr. Chesnutt argued that laws against race mixture violated the natural laws of natural and sexual selection, wherein any individual is free to attract a mate based on his or her own merit and beauty, thereby marrying ``up' in the social hierarchy. In this way, he believed, Southern law and custom merely served to impede the inevitable evolutionary solution to the race problem, complete race-amalgamation. In his novel the House Behind the Cedars (1900), especially, Chesnutt dramatizes this theory of racial evolution through sexual selection, wherein two very light-skinned and emphatically healthy blacks pass for white. Signaling her great admiration for Darwin, Edith Wharton, for example, published the Descent of Man and Other Stories (1904) and in many later stories and novels explored Darwinian materials with increasing depth and sophistication, often constructing plots based on the drama of mate selection, as in ``The Choice,' the Custom of the Country (1913), and the Reef (1912). In the last of these she also drew on her close reading in the most recent developments in Darwinism, such as R.

In this state symptoms norovirus buy generic mildronate on-line, dingy and hungry medications related to the integumentary system order mildronate 500 mg visa, she encounters Charles Drouet medicine search order mildronate cheap online, a traveling salesman who feeds her a good breakfast treatment integrity checklist discount mildronate 500 mg without a prescription, gives her some money, and buys her a stylish new jacket. Soon she is his mistress, living in a well-furnished apartment and ``altogether so turned about in all of her earthly relationships that she might well have been a new and different individual' (Dreiser 1981: 89). Between these two images she wavered, hesitating which to believe' (Dreiser 1981: 89). The internal voice of conscience admonishes, ``Remember how men look upon what you have done. Just as Dreiser deconstructs the opposition between surface and depth, so he deconstructs the Protestant opposition between authenticity and theatricality. If social roles are themselves performances, then theater can liberate us from the restrictions of everyday life. On stage we can speak words and express emotions that our ``real' roles would never allow. Theater provides access to aspects of the self that would otherwise remain forever hidden. The costumes, the sets, the make-up, all ``breathe of the other half of life in which we have no part, of doors that are closed, and mysteries which may never be revealed. Through these we may be admitted ­ through these get a glimpse of the joys and sorrows which we may never be permitted to feel on our own behalf' Literary Narratives and Consumer Culture 333 (Dreiser 1981: 176­7). She sees ``the beauty of the dresses upon the stage ­ the atmosphere of carriages, flowers, refinement. If all versions of reality are fictive, then the most frankly artificial is ironically the most sincere. Studying the ``magical order and sequence of dress,' she sees an ``ineffable charm' in material display, ``a halo about nice clothes, showy manners, sparkling rings' (Dreiser 1981: 23, 105). These goods, speaking ``tenderly and Jesuitically for themselves,' literally appeal to Carrie. Strange that a young woman who once assembled shoes in a factory should experience such goods as enchanted, animated, and ready to use their magic on her behalf. As a materialistic practice, commodity fetishism seemed, to Protestants at least, closely related to the equally mysterious transubstantiation of the sacraments. In Catholic doctrine, the sacraments received their transformative power through the consecration of the mass. The halo that appears about the goods Carrie desires appears to be the emanation of her own imagination. The power of goods thus comes not only from the capitalist apparatus of marketing and display, designed to stabilize the meaning of commodities, but also from the collective beliefs and political unconscious of consumers themselves. Just as Roman Catholics have to bring their faith to the communion table, so consumers have to bring their dreams to the department store. As Jackson Lears and William Leach point out, the marketplace retains an anarchic quality, a liberating potential for self-fashioning that goes back to the anti-authoritarian practices of the carnivalesque. Linked with the emergence of the cities, the growth of industry, and the transportation and communication revolutions, mass consumption was fueled by mass advertising, which spread a distinctly middle-class culture throughout American life. Goods were advertised in various ways: in mail-order catalogues from such establishments as Montgomery Ward and Sears Roebuck; through displays in department-store windows to entice passersby inside; and in nationally circulated magazines like the Ladies Home Journal and newspaper chains like those of the Hearst Syndicate (the circulation of daily newspapers increased by 900 percent between 1870 and 1910). White-collar purchasing power grew by over 30 percent between 1890 and 1910, leading to more disposable income and more leisure time. Advertisements for new labor-saving devices, furniture sets, readymade garments, and processed food pervaded the public psyche. Urban leisure led to the building of public parks, amusement parks, skating rinks, dance halls, theaters, movie palaces, and sports stadiums. Indoor electric lighting increased novel-reading, music-playing, and sales of books and sheet music. Women increasingly began leaving the domestic sphere to become clerks in department stores and to participate in the new world of fashion. One of the results of the rise of mass society was a subtle shift in the perception of the self, which was no longer assessed so much in terms of who a person was (character) or what they produced (work), but instead in terms of how they were seen by others (appearance) and how others judged them (personality). The culture of consumption also constructed anticipatory psyches, with the focus more on what one might hope to have in the future than on what one currently had in the present.

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For products specified by naming one or more products or manufacturers and "or equal" medicine 230 buy mildronate 250mg visa, Contractor must submit a request for substitutions of any product or manufacturer not specifically named in a timely manner so as not to adversely affect the construction schedule treatment 3 nail fungus best buy mildronate. Provide substantial platform medicine guide buy mildronate 250 mg fast delivery, blocking or skids to support fabricated products above ground to prevent soiling or staining symptoms 38 weeks pregnant purchase genuine mildronate on line. Cover products, subject to discoloration or deterioration from exposure to the elements, with impervious sheet coverings. Any weathering of products, coatings and finishes is not acceptable under requirements of these Contract Documents. The intent of this requirement is to reduce on-site storage time prior to installation and/or operation. Under no circumstances shall equipment be delivered to the site more than one month prior to installation without written authorization from the County. Moving parts shall be rotated a minimum of once weekly to insure proper Upon installation of the lubrication and to avoid metal-to-metal "welding". Lubricants shall be changed upon completion of installation and as frequently as required, thereafter during the period between installation and acceptance. Prior to acceptance of the equipment, the Contractor shall have the manufacturer inspect the equipment and certify that its condition has not been detrimentally affected by the long storage period. Such certifications by the manufacturer shall be deemed to mean that the equipment is judged by the manufacturer to be in a condition equal to that of equipment that has been shipped, installed, tested and accepted in a minimum time period. If such a certification is not given, the equipment shall be judged to be defective. A written notice that the work, or designated portion thereof, is substantially complete. Within a reasonable time after receipt of such notice, the County shall make an inspection to determine the status of completion. Project record documents and operations and maintenance manuals must be submitted before the project shall be considered substantially complete. The Contractor shall remedy the deficiencies in the work and send a second written notice of substantial completion to the County. The Engineer shall consider any objections made by the County as provided in Conditions of the Contract. The County shall make an inspection to verify the status of completion after receipt of such certification. The County shall promptly notify the Contractor in writing, listing the incomplete or defective work. The Contractor shall take immediate steps to remedy the stated deficiencies and send a second written certification to County that the work is complete. Upon finding the work to be acceptable under the Contract Documents, the County shall request the Contractor to make closeout submittals. Evidence of Payment and Release of Liens: In accordance with requirements of General and Supplementary Conditions. Certification letter from Florida Department of Transportation and Manatee County Department of Transportation, as applicable. Use only those cleaning materials and methods recommended by manufacturer of the surface material to be cleaned. Use cleaning materials only on surfaces recommended by cleaning material manufacturer. Provide on-site containers for the collection of waste materials, debris and rubbish. Remove waste materials, debris and rubbish from the site periodically and dispose of at legal disposal areas away from the site. Schedule operations so that dust and other contaminants resulting from cleaning process will not fall on wet or newly-coated surfaces. Prior to final completion or County occupancy, Contractor shall conduct an inspection of sight-exposed interior and exterior surfaces and all work areas to verify that the entire work is clean. Horizontal and vertical locations of underground utilities and appurtenances, referenced to permanent surface improvements. Locations of drainage ditches, swales, water lines and force mains shall be shown every 200 feet (measured along the centerline) or alternate lot lines, whichever is closer.

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An ill-sustained pupillary reaction (Marcus-Gunn pupil) is found in retrobulbar neuritis owing to afferent conduction defect treatment vaginitis mildronate 500 mg. It is found in the lesions of anterior visual pathway treatment zinc poisoning discount mildronate 500mg without a prescription, diabetes mellitus medicine pictures buy mildronate us, and pretectal lesions medications like adderall generic 500 mg mildronate visa. Abnormal pupillary reactions are encountered in the lesions of the visual pathway and the common ones are described here. The syphilitic lesion of the tectum affecting the pupillary pathway often results in Argyll-Robertson pupil wherein the pupils are small and the light reaction is impaired, but the reaction to convergence and accommodation is retained. Apparently a tonic pupil does not react to light and convergence, but careful examination reveals a very sluggish reaction with long latent period. Small constricted pupils (miosis) are found in persons using topical miotics or systemic morphine. Other causes of small constricted pupils are irritation of third nerve by pontine hemorrhage and sympathetic paralysis. A unilateral miosis due to sympathetic paralysis is accompanied with narrowing of palpebral fissure, slight enophthalmos and unilateral absence of sweating. Dilatation of pupils (mydriasis) occurs after instillation of mydriatic or cycloplegic drugs and the patient often has difficulty in doing near work. The common causes of pupillary dilatation are- acute congestive glaucoma (large vertically oval pupil), absolute glaucoma, optic atrophy, third nerve palsy (ophthalmoplegia interna) following meningitis, encephalitis, lead poisoning or orbital. Sometimes, unilateral dilatation of pupil may occur from irritation of the cervical sympathetics by enlarged cervical glands in the neck, apical pleurisy, cervical rib, meningitis and acute anterior poliomyelitis. Many of these cases subsequently develop pupillary constriction from sympathetic paralysis. A small, irregular, sluggishly reacting or immobile pupil associated with muddiness of the iris is the hallmark of iritis. Irregularity and immobility of the pupil occur due to posterior synechiae, and instillation of a mydriatic results in a festooned or pear-shaped incompletely dilated pupil. It is not rare to find ectropion of pigments over the pupillary border after anterior uveitis. Rarely, the pupillary aperture is completely occluded by exudates-occlusio pupillae. The pupil of an adult looks gray owing to the scattering of light from the lens surface. A white pupillary reflex in infants and young adults must arouse the suspicion of retinoblastoma and pseudoglioma, respectively. Examination of the Lens the lens of the eye is a transparent structure and, as such, cannot be thoroughly examined without 64 Textbook of Ophthalmology the help of a slit-lamp. On focal illumination, the lens of youngsters appears almost clear or gives a faint bluish hue. Mere presence of lenticular haze by oblique illumination does not warrant the diagnosis of cataract as the refractive index of the lens increases with the age and causes marked scattering of light contributing to the haze. Therefore, the findings must be confirmed either by ophthalmoscopic examination or by distant direct examination by a plane mirror. The slit-lamp examination provides an optical section of the lens which shows from within outward-embryonic nucleus, fetal nucleus, infantile nucleus, adult nucleus, cortex and capsule. Any opacity in the lens is called cataract which may be either developmental or acquired. The developmental cataract affects a particular zone of the lens and may or may not cause impairment of vision. Among the acquired cataracts, senile cataract is the commonest which may manifest either in a cortical or a nuclear form. They coalesce and form a white, more or less, total opacity also known as soft cataract. An accentuation of the process of lenticular sclerosis results in nuclear cataract. The lenticular opacities appear black against a red fundus reflex when viewed by a plane mirror or an ophthalmoscope. Usually, the first and the fourth images are clearly visible on pupillary dilatation. However, the second and third images can only be recognized in a dark room with the help of a brilliant light. The subluxated lens can be diagnosed by segmental tremulousness of the iris, presence of the edge of the lens in the pupillary area and demonstration of phakic and aphakic areas by retinoscopy or ophthalmoscopy.

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