By Q. Yussuf. University of New Haven. 2018.

Although some vaccines were developed earlier order carisoprodol 350 mg mastercard, the number and impact of vaccines developed in the 1900s century was monumental purchase carisoprodol 350mg free shipping. The renamed Centers for Disease Control and Prevention in 1999 published a review of the 10 great public health achievements in the United States during the 1900s order 350 mg carisoprodol mastercard. The vaccines developed and licensed to prevent vaccine-preventable diseases are shown in Table 1-3, and an estimate of their effect on reported infectious disease morbidity is shown in Table 1-4. During the previous century, the average life span of persons in the United States lengthened by about 30 years, and 25 years of this gain has been attributed to advances in public health. During the 1900s, infectious R1 disease mortality declined from about 800/100,000 population to under © Jones and Bartlett Publishers. The effectiveness of treatments and vaccines coupled with increased fnancial support fueled spectacular advances as the underlying science of diseases was unraveled. Since that time gradual progress in deciphering and manipulating the genetic code of animals and plants had occurred. Dolly the sheep, born July 5, 1996, was the frst higher animal to be cloned, and several other animals have followed. The project was completed ahead of schedule and in April 2003 the human genome was published in several articles in Nature and Science. The felds of genomics and proteomics, the study of protein expression, are rapidly evolving felds that hold great promise for understanding the interaction of humans with infec- tious pathogens. This genome will be informative for all grains, as rice, corn and wheat diverged from a common grass ancestor only 50,000 years ago. Earlier researchers manipulated the rice genome to insert a daffodil gene which added vitamin A to rice. Unfortunately, although genetically modifed foods hold great promise, they are also highly controversial. Hardier plants, enhanced with insect repel- lant genes or drought resistance, threaten to drive out native plants, which could ultimately reduce global genetic diversity. Highly successful seeds are patented, and this elevates the cost of seed beyond the reach of subsistence farmers. The concentration of ownership of seeds is severe, and only a handful of companies own the rights to most of the food seed sold in the world. The Infectious Diseases Challenge In the previous century, such spectacular progress was made in infectious disease control that many health professionals felt that antibiotics and vac- cines would soon eliminate infectious disease threats from most developed nations. Unfortunately, drug resistant strains of tuberculosis have also emerged making control even more diffcult. Several other diseases emerged, or reemerged, in the last of the previous century. The unfounded optimism of the mid-1900s has been replaced by greater resolve to solve some of the most intractable problems in infectious diseases. The remainder of this book will lay out the techniques and tools of infectious disease epidemiology and then describe some of the important infectious diseases. The book is not intended to be a comprehensive study of all infectious diseases, but we hope it will give the fundamental tools and knowledge necessary to advance the readers understanding of infectious disease epidemiology. An account of the bilious remitting fever as it appeared 1515 in Philadelphia in the summer of 1780. Observations Made During the Epidemic of Measles in the Faroe Island in the Year 1846. Nvove verme intestinalumano (Ancylostoma duodenale) constitutente un sestro gemere dei nematoide: proprii delluomo. Assadian O, Stanek G Theobald Smith—the discoverer of ticks as vectors of disease. Batelle Medical Technology Assessment and Policy Research Program, Center for Public Health Research and Evaluation. Ten great public health achievements—United States, 1900–1999, control of infectious diseases. Transgenic rice (Oryza sativa) endosperm expressing daffodil (Narcissus pseudonarcissus) phytoene synthase accumulates phytoene, a key intermediate of provitamin A biosynthesis. Improving the nutritional value of golden rice through increased pro-vitamin A content. Effects of vitamin A supplementation on immune responses and correlation with clinical outcomes. Kaposi’s sarcoma and Pneumocystis pneumonia among homosexual men—New York City and California. It is hard to tell what goes with what here, including the names of the scientists. If he’s part of the diphtheria crew then change the names to “Klebs, Loeffer, and Gaffky”.

Let your patients know This should occur as early as possible and should be as soon as is feasible order carisoprodol 350 mg amex. The resident imme- available should disclose their concerns to their diately goes to their supervisor and explains that they feel employer or clinical chief and negotiate an appropri- they cannot participate in the requested procedure generic 500 mg carisoprodol with amex. After discussion with the program direc- concerns with the institution and their clinical chief tor it is decided that the resident should not complete the before starting their rotation generic 350mg carisoprodol with visa. The resident is still able to complete residency, qualifes as an obstetrician and gynecologist, and now ensures that The most contentious issues are whether a physician must assist their patients know the limits of their practice. Some physicians believe that even generating a referral makes them complicit in the provision of a treatment College of Physicians and Surgeons of Ontario. Physicians or procedure that they believe to be wrong, and point to the and the Ontario Human Rights Code [policy #5-08]. However, some provincial colleges may consider this loadedFiles/downloads/cpsodocuments/policies/policies/ to fall below the standard of care should a complaint arise. Abortion: ensuring access Although a patient’s choices should not be limited by a physi- [editorial]. It also seems unlikely that an individual physician would face sanction in this situation, even though it is an unacceptable situation for the patient. Often an institution or region will have to provide the resources needed to connect the patient to the procedure in a timely manner (e. In such cases, do everything possible to offer ap- This chapter will propriate interventions. In some situations, Case the patient or family member might respond only to someone A second-year resident attends to a patient who, in spite of they perceive to have more authority. In such cases, do not take appropriate and excellent care, develops signifcant medi- the situation personally. When the resident shares this news with Return to observe how your supervisor manages the situation the patient and his family, the resident is verbally abused and see if you can re-engage in a collaborative relationship and begins to fear for their own safety. Family members begin to discuss information about the Key strategies to ensure physical safety resident found online and start to make threatening re- • Request that your program offer training in non- marks about the resident’s family. Ask colleagues for an update, Introduction and read the chart before seeing the patient. Taking the role of patient can be an uncomfortable situation • Learn how to read the signs of imminent aggression. When we do fnd ourselves in this role, our • Acknowledge the person’s distress and ask what emotions may range from simple irritation to frank terror. Meanwhile, physicians are often the bearers of • If you perceive danger, terminate the interview bad news. Immediately seek help, including from very fact that they are needed is in almost every circumstance security staff or police as needed. And fnally, along Patients or family members sometimes feel wronged or acutely with their physicians, patients are faced with the stresses of frustrated at not getting what they want. This may provoke accessing care within a health care system that is complex and them to make physical threats or to challenge your professional strained. Offer to listen to the concerns of the patient or fam- These stressors can cause diffculties in communication and ily member again. This chapter will outline some of the acknowledging that you can minimize the threat. Encourage critical aspects of patient–physician confict and present strat- the person to put his or her concerns and desired outcomes egies to reduce risk. Consider inviting a third party such as your chief resident or supervisor to help. Finally, respect any request to Verbal aggression make a complaint by directing the person to the appropriate Aggression can be triggered by many emotions, perhaps the channels and indicating that feedback is welcome. If a patient or family member becomes verbally aggressive, acknowledge their feelings gently Intimidation but clearly. It is important to have insight into your own responses to be- At the same time, ask them to help you by remaining calm. Some people are uncomfortable with confict and In other cases, verbal aggression may be a presenting sign to avoid confrontation become submissive. Others respond to bullying with certifcation program offered by the Crisis Prevention Institute a strong reaction that may be experienced by the patient as (www. Clearly explain that you In general, the least experienced members of the team are the want to work collaboratively with the patient, and offer the most at risk of being injured. Emphasize what you are, or are not, willing unless you have been appropriately trained. If appropriate, indicate that you can arrange for or family member represents a serious emergency; alert the the patient to be seen by another physician if he or she prefers. Finally, be mindful that any medi- member of the team to join you when you see the patient.

This plan will be transparent purchase carisoprodol 350 mg with amex, accessible to patients and their families purchase carisoprodol 350 mg visa, and customizable carisoprodol 500mg line, enabling the clinical team and patients to examine the studies, data, and justifications for recommended care. Dissemination and Care-decision Capabilities Information technology will enable expert medical knowledge to pervade our societies, transcending the constraints of geography, language, and local infrastructure. Finally, information will enable pa- tients and their families to have more control over their own lives and health. It will provide them secure and reliable personal health records and a “dashboard” on their home computer’s web browser that will help them manage their relationship to their doctors, hos- pitals, pharmacies, and the rest of the health system. The technologies you will learn more about in this book—electronic medical records, clinical decision support, genetic diagnosis, medical imaging, telemedicine, The Information Quagmire 11 digital business systems in health insurance and health systems— are all connected by the Internet to one another. The Internet pro- vides both the connectivity for all these different but reinforcing technologies and the lubricant of information flow throughout the health system. Between this potential and today’s information quagmire stands a huge societal commitment: an expenditure that could exceed $300 billion in the United States alone over the next ten years. Healthcare or- ganizations of all types face a large skill gap in adapting these power- ful new tools and a steep learning curve for the firms providing the technology. However, healthcare institutions and professions must take on the challenge to implement technology, a task that includes the concepts and processes described in this book. In the pre-digital age we are leaving, the vital knowledge about medical history and treat- ment options would have been found imprisoned in paper and film—in the form of multiple medical records, medical texts, and journals—or locked in the memories of those who have recently provided care. The only way for the care team to use this informa- tion was to have physical possession of it, read it, and interpret it in an effort to figure out a treatment plan. Furthermore, for care team members to develop and implement such a plan, two or more members typically needed to be on the telephone at the same time or in the same room to coordinate their efforts. In the digital age we are entering, vital information and knowl- edge about conditions, as well as how to treat them, will become as mobile as quicksilver. This information will be able to travel anywhere in the world with broadband connectivity at the speed of light. Every piece of this knowledge about patients and the medical problems confronting them will be converted over the next decade from paper and film to digital files. Moreover, to use that knowl- 13 edge, the only thing that caregivers will need is access to a computer system connected to patients’ records. Yet the big picture—the extent of the revolution—has eluded healthcare providers, because they cannot see how all these tech- nologies will come together to change how the care team behaves and how consumers interact with the health system. This chapter explores this convergence by looking at the different knowledge domains—molecular and cellular, tissues and organ systems, care processes—relevant to treatment. It also discusses the technical as- pects of care as they evolve and how they will affect healthcare delivery, including remote medicine, the Internet, and electronic medical records. The chapter continues with an examination of a navigation system for clinical care and the prospects for its use by physicians in a teacher/protector role, and it concludes by addressing technical requirements for the digital revolution to continue. It is digital software—the most complex software known in the universe—comprising three billion bits of chemical “code” embedded in the nucleus of each cell in the body. This amazing molecule contains not only the template for every one of the hundreds of thousands of proteins in the body, but also the assembly instructions for turning those proteins into a functioning human being. Most major illnesses troubling patients today, including heart disease, cancer, Alzheimer’s disease, and many forms of mental ill- ness, have genetic roots. As Matt Ridley remarks in his poetic and insightful book, Genome, genes are not there to cause disease, but to support normal functioning. Genomics is information technology; shut down the computers, and modern cell biology rapidly grinds to a halt. With the completion of the Human Genome Project in late 2000, western society was inundated with a great deal of hype heralding the seemingly immediate impact that mapping the lo- cation of all of a person’s genes would have on his or her health. It seemed for a brief, giddy moment that a new wave of genetically based cures for disease would shortly be unleashed. When asked what stood between the gene map and a comprehensive understanding of human disease, one scientist, Dr. William Neaves of the Stowers Institute of Medical Research, responded, “About one hundred years of hard work. These genes fluidly and continuously interact with a person’s environment, his or her behavior, and each other in a bewilderingly complex manner to create disease risk. Translating information about genetic risk of disease into focused prevention, such as gene therapy, that extinguishes disease risk at the molecular level, remains a daunting scientific and technical challenge. However, one hundred years will not have to pass before genetic information reshapes healthcare. This signature is then 16 Digital Medicine compared to computer libraries of known strains of the virus that are susceptible or resistant to various drugs in the therapeutic cocktail. By tailoring the elements and dosages in the cocktail to the genetic signature of the virus, far more rapid and efficient clearing of the virus has been achieved. Giving the drug to patients whose cells do not display this receptor means wasting $20,000 on a drug with no clinical effect. Many new drugs will be approved in the next few years conditional upon a genetic test to determine if the therapy is likely to be effective.

Crit tors: A comparison of epinephrine and norepinephrine in critically ill Care Med 2004 discount carisoprodol 350mg with mastercard; 32:1928–1948 patients carisoprodol 500mg without a prescription. Morelli A purchase 500mg carisoprodol with mastercard, Ertmer C, Rehberg S, et al: Phenylephrine versus nor- sure on tissue perfusion in septic shock. Crit Care Med 2000; epinephrine for initial hemodynamic support of patients with septic 28:2729–2732 shock: A randomized, controlled trial. Crit Care Med 2000; 28:2758–2765 term vasopressin infusion during severe septic shock. De Backer D, Creteur J, Silva E, et al: Effects of dopamine, nor- ogy 2002; 96:576–582 epinephrine, and epinephrine on the splanchnic circulation in septic 159. Crit Care Med 2003; 31:1659–1667 advanced vasodilatory shock: A prospective, randomized, controlled 138. Circulation 2003; 107:2313–2319 adrenaline infusions on acid-base balance and systemic haemody- 160. Lancet 2002; 359:1209–1210 nephrine and dobutamine to epinephrine for hemodynamics, lac- 165. Sharshar T, Blanchard A, Paillard M, et al: Circulating vasopressin tate metabolism, and gastric tonometric variables in septic shock: levels in septic shock. Confalonieri M, Urbino R, Potena A, et al: Hydrocortisone infusion 31:1394–1398 for severe community-acquired pneumonia: A preliminary random- 168. Am J Respir Crit Care Med 2005; 171:242–248 in hyperdynamic septic shock: A prospective, randomized study. Morelli A, Ertmer C, Lange M, et al: Effects of short-term simultane- monia: A randomised, double-blind, placebo-controlled trial. Bellomo R, Chapman M, Finfer S, et al: Low-dose dopamine in ized, controlled clinical trial of transfusion requirements in critical patients with early renal dysfunction: A placebo-controlled ran- care. Australian and New Zealand Intensive Care Society dian Critical Care Trials Group. Annane D, Sébille V, Charpentier C, et al: Effect of treatment with transfusion does not increase oxygen consumption in critically ill low doses of hydrocortisone and fudrocortisone on mortality in septic patients. Briegel J, Forst H, Haller M, et al: Stress doses of hydrocortisone binant human erythropoietin in the critically ill patient: A random- reverse hyperdynamic septic shock: A prospective, randomized, ized, double-blind, placebo-controlled trial. Crit Care als Group: Effcacy of recombinant human erythropoietin in Med 1998; 26:645–650 critically ill patients: A randomized controlled trial. College of American Pathologists: Practice parameter for the use 2008; 358:111–124 of fresh-frozen plasma, cryoprecipitate, and platelets. Clin Infect Dis 2009; 49:93–101 ponent Therapy: Practice guidelines for blood component therapy. Crit Care 2002; 6:251–259 transfusion on prothrombin time and bleeding in patients with mild 184. Transfusion 2006; 46:1279–1285 Multicenter comparison of cortisol as measured by different meth- 205. Intensive Care Med 2009; 35:1868–1876 Clinical Oncology: Platelet transfusion for patients with cancer: Clin- 188. Keh D, Boehnke T, Weber-Cartens S, et al: Immunologic and hemo- ical practice guidelines of the American Society of Clinical Oncol- dynamic effects of “low-dose” hydrocortisone in septic shock: A ogy. Br J Haematol 2003; Group: Drotrecogin alfa (activated) for adults with severe sepsis and 122:10–23 a low risk of death. Lancet 2007; 369:836–843 Treatment of neonatal sepsis with intravenous immune globulin. Darenberg J, Ihendyane N, Sjölin J, et al; StreptIg Study Group: Intra- ratory distress syndrome: The Berlin defnition. Clin Infect Dis 2003; 37:333–340 lower tidal volumes as compared with traditional tidal volumes for 215. N globulin in neutropenic patients with sepsis syndrome and septic Engl J Med 2000; 342:1301–1308 shock: A randomized, controlled, multiple-center trial. Rodríguez A, Rello J, Neira J, et al: Effects of high-dose of intrave- N Engl J Med 1998; 338:347–354 nous immunoglobulin and antibiotics on survival for severe sepsis 236. Brochard L, Roudot-Thoraval F, Roupie E, et al: Tidal volume reduc- undergoing surgery. Shock 2005; 23:298–304 tion for prevention of ventilator-induced lung injury in acute respi- 217. Crit tidal volume ventilation in acute respiratory distress syndrome Care Med 2007; 35:2686–2692 patients. Crit strategy to prevent barotrauma in patients at high risk for acute respi- Care Med 2007; 35:2677–2685 ratory distress syndrome. N Engl J Med 1998; 338:355–361 nous immunoglobulin in critically ill adult patients with sepsis. Putensen C, Theuerkauf N, Zinserling J, et al: Meta-analysis: Ventila- infammatory response syndrome, sepsis, and septic shock. Crit tion strategies and outcomes of the acute respiratory distress syn- Care Med 2007; 35:118–126 drome and acute lung injury.

When the full patient dose distribution is available in the data samples used carisoprodol 350mg overnight delivery, other optimization options could be considered and implemented (such as decreasing high dose tails in the distributions and discriminating individual high dose values for clinical follow-up) discount carisoprodol 350mg with amex. Worldwide surveys of interventional cardiologists from 32 countries and 81 regulatory bodies from 55 countries provided information on dosimetry practice: only 57% of regulatory bodies define the number and/or position of dosimeters for staff monitoring and less than 40% could provide doses cheap carisoprodol 500 mg online. The survey results proved poor compliance with staff monitoring recommendations in a large fraction of hospitals and the need for staff monitoring harmonization and monitoring technology advancements. In fact, the interventionalist doctor operates in a radiation area where a cumulative annual equivalent ambient dose up to 2 Sv at about 0. A final goal is to establish an international database for the regular collection of occupational dose data in targeted areas of radiation use in medicine, industry and research. Eighty one regulatory bodies answered and only 50% provided some occupational dose data. Of these, there was a wide variety of responses, ranging from detailed, accurate dose values to data that were inconsistent and/or ambiguous. This probably over-optimistic picture is indicative of the fact that dosimeters are not always used and different monitoring protocols are applied. The great number of unrealistic zero values were analysed, taking into account factors such as dose reporting consistency and dose value consistency. The development of a quality factor made it possible to filter dose data (right panel in Fig. Over apron mean and maximum annual dose of haemodynamists, electrophysiologists, nurses and technologists in a sample of ten Italian hospitals [10]. Several authors have assessed different algorithms to estimate the effective dose from the reading of the over and under apron dosimeters. Eye monitoring can be performed with specifically designed eye dosimeters, measuring and calibrated for Hp(3), difficult for continuous use in practice. More frequently, eye dose is estimated from the reading of a dosimeter at the neck over the apron, applying correction factors in the range of 0. For all these reasons, the accuracy of eye lens dose estimation is very low and, probably, not acceptable for dose levels of the same order of the dose limit. For the high gradient of dose when the hand is near the X ray field edge, the measurement should be performed with a ring dosimeter facing the X ray tube on the little or ring finger of the most exposed hand. In this case, the accuracy estimated is 10–30% compared to an underestimation up to a factor of three for a bracelet dosimeter [2]. In summary, improvements in dose monitoring are necessary to: — Develop a more robust monitoring system increasing the accuracy of effective dose and, mainly, eye lens dose assessment; — Develop active dosimeters designed for interventional practice to provide doses in real time. Education and training in radiation protection is the primary action to implement. Several guidelines and training tools have been developed over the past decade, and training and training certification should be mandatory by law. Optimization tools should be developed to assist staff exposure optimization: achievable and investigation levels expressed in dose per patient dose unit and procedure type should be assessed and adopted, together with the achievable and reference levels for patient exposure optimization. These methods can have better efficacy if information systems collecting patient and staff exposures become available. International and standardization bodies should develop standards and manufacturers should develop instruments able to provide integrated information to practitioners and audit teams. Although many resources have been allocated to the setting up of referral guidelines/appropriateness criteria by various national radiological societies, institutions and commissions [4–6], more efforts to address this gap are required, through understanding the issues behind the failure of proper justification and increased awareness through education. The possible causes of poor justification include the practice of self-referral, financially motivated referrals, reimbursement patterns, the practice of defensive medicine and low levels of knowledge of the radiation doses involved in radiological procedures [7]. Further dose reduction may be gained from protocols being optimized for various specific clinical indications instead of having broad generic protocols. Whole body scans in just a few seconds with submillimetre spatial resolution are possible today. In addition, cardiac imaging at very high temporal resolution is routinely performed, offering motion-free diagnosis of the coronary artery tree. The latter figure is not necessarily relevant, as only patients are exposed when a relevant indication is given but not the general public. Fortunately, the technological developments of the past have not only provided improved diagnostic capabilities but also ways of limiting or reducing patient dose significantly. There are comprehensive data on the exposure to the patient per examination category in the European Union. The European Commission Radiation Protection Report [1], for example, states that the effective dose per examination was, on average, below 10 mSv in the early 2000s. Quite a number of technological advances were introduced over the past decade; a list of five important steps to be considered is given in Table 1. Dose efficient X ray detectors Considerations regarding the optimal choice of X ray spectra have been neglected for many decades.

Himself a highly experienced anato- mist buy generic carisoprodol 350mg on-line,103 Galen no more than Soranus could accept the possibility that the womb actually wandered to various parts of the body since the diaphragm purchase carisoprodol 350 mg on line, if nothing else carisoprodol 500 mg line, absolutely prohibited movement to the thorax. He did not, however, question the by now traditional litany of symptoms, let alone the existence of the disease category. He, like Soranus, thought the womb could appear to be drawn up slightly because of inflammation of the ligaments. Yet to explain apnoia hysterike (difficulty of breathing caused by the uterus), Galen offered something of a compromise that would explain how the uterus, with- out moving to the upper parts, could still affect them. He posited a sympa- thetic poisonous reaction caused by either the menses or the woman’s own semen being retained in her uterus. Notable here is Galen’s shift in ideas about how semen and sexuality played into this dis- ease: for Galen, it was not her lack of semen provided by a man that made the widow susceptible, but the buildup of her own seed. Despite these dis- agreements,Galen maintained elements of the traditional odoriferous therapy, though he complemented this with bloodletting, massage, and a host of other treatments. Both Soranus and Galen represented the very highest theoretical tradi- tions of Greek medicine, catering as they did to the elite, Hellenized urban classes of Rome. Their views never eradicated what were apparently deeply rooted popular beliefs that the womb did indeed wander. Even Muscio, in the fifth or sixth century when hewas rendering Soranus into Latin, slipped in the more than suggestive phrase ‘‘when the womb moves upwards toward the chest’’ when referring to uterine suffocation; as he repeated this several times, it seems that he, too, thought the womb capable of more than ‘‘distension caused by the ligaments. One is written into a blank space of a late-ninth-century medical volume by a tenth-century Introduction  hand. Having invoked the aid of the Holy Trinity, the nine orders of the an- gels, the patriarchs, prophets, apostles, martyrs, confessors, virgins, and ‘‘all the saints of God,’’ the priest is to command the womb to cease tormenting the afflicted woman: I conjure you, womb, by our lord Jesus Christ, who walked on the water with dry feet, who cured the infirm, shunned the demons, resuscitated the dead, by whose blood we are redeemed, by whose wounds we are cured, by whose bruise[s] we are healed, by him I conjure you not to harm this maidservant of God, [her name is then to be filled in], nor to hold on to her head, neck, throat, chest, ears, teeth, eyes, nostrils, shoulders, arms, hands, heart, stomach, liver, spleen, kidneys, back, sides, joints, navel, viscera, bladder, thighs, shins, ankles, feet,or toes, but to quietly remain in the placewhich God delegated to you, so that this handmaiden of God, [her name], might be cured. The chief vehicle for Galen’s views in the twelfth century was, of course, Ibn al-Jazzār’s Viaticum. In discussing uterine suffo- cation in book , Ibn al-Jazzār had echoed Galen in asserting that ‘‘the sperm increases, corrupts, and becomes like a poison. Ibn al-Jazzār postulated that the putrefying menses and/or semen in the uterus produced ‘‘a cold vapor’’ that rose to the diaphragm. In the main chapter on uterine suffocation (¶¶– ), the author closely follows the Viaticum in laying out the standard litany of symptoms, recounting Galen’s cure (from On the Affected Parts), and positing the same causation: corrupted semen (or menses) is turned into a ‘‘venom- ous nature,’’ and it is this ‘‘cold fumosity’’ that ascends up to ‘‘the parts which are commonly called the corneliei, which because they are close to the lungs and the heart and the other organs of the voice, produce an impediment of speaking. This chapter (¶) is drawn from the alternate source, the Hippocratic Book on Womanly Matters. In the ‘‘rough draft’’ of Con- ditions of Women,theTreatise on the Diseases of Women, it was stated very clearly that movement of the womb to the upper body was possible: ‘‘Sometimes the womb [moves] from its place, so that it ascends up to the horns of the lungs, that is, the pennas [feathers], and [sometimes] it descends so that it goes out  Introduction of [the body] and then it produces pain in the left side. And it ascends to the stomach and swells up so much that nothing can be swallowed. The sign of this is that she feels pain in the left side, and she has distention of the limbs, difficulty swallowing, cramping, and rumbling of the belly. What this change in phrasing from the first draft does is dis- tinguish three nosological conditions: movement up to the respiratory organs (discussed in ¶¶–), prolapse downward, sometimes with complete extru- sion (¶¶–), and this third intermediate condition where it goes neither up nor all the way down. Conditions of Women’s allusions suggest that the ‘‘wandering womb’’ was indeed part of the general belief structure in southern Italyat this time. The ten- sion between, on the one hand, the Galenic/Arabic view of uterine suffocation as caused by either a sympathetic link between uterus and respiratory organs or the actual physical transmission of a noxious vapor and, on the other hand, the traditional Hippocratic idea of the ‘‘wandering womb’’ finds a graphic ex- pression in the work of Johannes Platearius, another Salernitan writer working at perhaps the same time that Conditions of Women was composed. Johannes Platearius had interpreted Ibn al-Jazzār’s reference to ‘‘fumes’’ as meaning that the fumes filled the uterus and caused it to move upward to the respiratory organs. Interestingly, he asserts that it is women who say they ‘‘have their womb in their stomach’’ or in their throat or at their heart. It was a gen- eral medical assumption throughout most of the medieval period that women needed regular sexual activity in order to remain healthy. Indeed, Soranus’s distinctive views on sexu- ality were suppressed when Muscio’s Gynecology was twice readapted to new uses in or before the eleventh century. Johannes Platearius went farther than Conditions of Women in reincorporating the traditional Hippocratic recommendation of sex and marriage as suitable, even preferable cures: ‘‘If [the disease] occurs because of corrupt semen, let her know her husband. This is, nevertheless, one of the first acknowledgments by a medical writer of a category of Christian women who were chaste not by force of circumstance but by individual choice. Although not produced at the same time as the Trotula text found within this manuscript, these images do offer vivid evidence of how medical theory and practice may have been played out. First, on the top of the recto side of folio , we see the woman falling in a seizure; the dog with her signifies that she is of noble status, though it perhaps also indicates that she has only her pet to keep her company. In the upper half of the verso page, we see her as if dead, already laid out on a bier while her servants, apparently, mourn her death. The bowl on her chest points to an amplification that Platearius made on the Viaticum’s text when he suggested that the woman’s condition could be determined by either a flock of wool placed to the nose or a glass bowl placed on the chest. Just as the wool would move slightly with her breath, so the water in the bowl would, by its slight vibrations, show that she was still alive. Illustrations of a case of uterine suffocation from a late thirteenth- century English manuscript. The final frame depicts the kinds of women most susceptible to uterine suffocation: widows (note the prayer- book falling from the hand of the veiled woman) and virgins who have just reached the age of marriage.

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