Jeffrey A Brinker, M.D.
- Professor of Medicine
- Joint Appointment in Radiology and Radiological Science
In the 1980s about 75% of reported cases were attributable to cheapest generic colchicine uk fungal infection contact with affected animals; in recent outbreaks it appears that a larger number of cases were attributable to buy colchicine amex antimicrobial jacket person-to-person contact buy generic colchicine 0.5mg on line antibiotics for dogs uti. The longest chain of person-to-person transmission was 7 reported serial cases, but serial transmission usually did not extend beyond secondary. Most cases have occurred either singly or in clusters in small remote villages, usually in tropical rainforest where the population has multiple contacts with several types of wild animals. Ecological studies in the 1980s point to squirrels (Funisciurus and Heliosciurus), abundant among the oil palms surrounding the villages, as a signicant local reservoir host. Maintenance of an animal reservoir and animal contact is required to sustain the disease among humans. Thus, human infection may be controllable by education to limit contact with infected cases and potentially infected animals. Monkeypox virus is a species of the genus Orthopoxvirus, with biological properties and a genome map distinct from variola virus. There is no evidence that monkeypox will become a public health threat outside of enzootic areas. IdenticationA fungal disease, usually of the skin, often of an extremity, which begins as a nodule. As the nodule grows, lymphatics draining the area become rm and cord-like and form a series of nodules, which in turn may soften and ulcerate. OccurrenceReported worldwide, an occupational disease of farmers, gardeners and horticulturists. An epidemic among gold miners in South Africa involved some 3000 people; fungus was growing on mine timbers. Mode of transmissionIntroduction of fungus through the skin pricks from thorns or barbs, handling of sphagnum moss or slivers from wood or lumber. Outbreaks have occurred among children playing in and adults working with baled hay. Period of communicabilityPerson-to-person transmission has only rarely been documented. Preventive measures: Treat lumber with fungicides in industries where disease occurs. Wear gloves and long sleeves when working with sphagnum moss, and use personal protection when handling sick cats. Control of patient, contacts and the immediate environment: 1) Report to local health authority: Ofcial report not ordinarily justiable, Class 5 (see Reporting). In the South African epidemic, mine timbers were sprayed with a mixture of zinc sulfate and triolith in order to control the epidemic. A pus-containing lesion (or lesions) is the primary clinical nding, abscess formation is the typical pathological manifestation; production of toxins may also lead to staphylococcal diseases, as in toxic shock syndrome. However, coagulase-negative strains are increasingly important, especially in bloodstream infections among patients with intravascular catheters or prosthetic materials, in female urinary tract infections and in nosocomial infections. Staphylococcal disease has different clinical and epidemiological patterns in the general community, in newborns, in menstruating women and among hospitalized patients; each will be presented separately. Staphylococcal food poisoning, an intoxication and not an infection, is also discussed separately (see Foodborne intoxications, section I, Staphylococcal). IdenticationThe common bacterial skin lesions are impetigo, folliculitis, furuncles, carbuncles, abscesses and infected lacerations. Usually, lesions are uncomplicated, but seeding of the bloodstream may lead to pneumonia, lung abscess, osteomyelitis, sepsis, endocarditis, arthritis or meningitis. In addition to primary skin lesions, staphylococcal conjunctivitis occurs in newborns and the elderly. Staphylococcal endocarditis and other complications of staphylococcal bacteraemia may result from parenteral use of illicit drugs or nosocomially from intravenous catheters and other devices. Embolic skin lesions are frequent complications of endocarditis and/or bacteraemia. Coagulase-negative staphylococci may cause sepsis, meningitis, endocarditis or urinary tract infections and are increasing in frequency, usually in connection with prosthetic devices or indwelling catheters. Most strains of staphylococci may be characterized through molecular methods such as pulsed-eld gel electrophoresis, phage type, or antibiotic resistance prole; epidemics are caused by relatively few specic strains. The majority of clinical isolates of Staphylococcus aureus, whether communityor hospital-acquired, are resistant to penicillin G, and multiresistant (including methicillin-resistant) strains have become widespread. Evidence suggests that slime-producing strains of coagulase-negative staphylococci may be more pathogenic, but the data are inconclusive. Highest incidence in areas where hygiene conditions (especially the use of soap and water) are suboptimal and people are crowded; common among children, especially in warm weather. The disease occurs sporadically and as small epidemics in families and summer camps, various members developing recurrent illness due to the same staphylococcal strain (hidden carriers). Mode of transmissionThe major site of colonization is the anterior nares; 20%30% of the general population are nasal carriers of coagulase-positive staphylococci. Persons with a draining lesion or purulent discharge are the most common sources of epidemic spread. Transmission is through contact with a person who has a purulent lesion or is an asymptomatic (usually nasal) carrier of a pathogenic strain. The role of contaminated objects has been overstressed; hands are the most important instrument for transmitting infection. Airborne spread is rare but has been demonstrated in patients with associated viral respiratory disease.
- Pulmonary hypertension
- Rheumatoid factor and ANA test will be negative.
- Every 5 years if your results were normal
- Has the diet been changed recently?
- Removing blood or blood clots if they are raising pressure inside the skull and causing herniation
- Check lung function before someone has surgery
Control of patient generic 0.5mg colchicine visa antimicrobial and antibacterial, contacts and the immediate environment: 1) Report to buy colchicine 0.5mg low price antibiotic resistance reasons local health authority: In selected endemic areas; in most countries buy 0.5mg colchicine antibiotics bad for you, not a reportable disease, Class 3 (see Reporting). Epidemic measures, Disaster implications and International measures: See Yaws, C, D and E. IdenticationA specic zoonosis involving rodents and their eas, which transfer the bacterial infection to various animals and to people. Initial signs and symptoms may be nonspecic with fever, chills, malaise, myalgia, nausea, prostration, sore throat and headache. Lymphadenitis often develops in those lymph nodes that drain the site of the bite, where there may be an initial lesion. This is bubonic plague, and it occurs more often (90%) in lymph nodes in the inguinal area and less commonly in those in the axillary and cervical areas. All forms, including instances in which lymphadenopathy is not apparent, may progress to septicemic plague with bloodstream dissemination to diverse parts of the body that include the meninges. Secondary involvement of the lungs results in pneumonia; mediastinitis or pleural effusion may develop. Secondary pneumonic plague is of special signicance, since respiratory droplets may serve as the source of person-to-person transfer with resultant primary pneumonic or pharyngeal plague; this can lead to localized outbreaks or devastating epidemics. Though naturally acquired plague usually presents as bubonic plague, purposeful aerosol dissemination as a result of deliberate use would be manifest primarily as pneumonic plague. Plague organisms have been recovered from throat cultures of asymptomatic contacts of pneumonic plague patients. Modern therapy markedly reduces fatality from bubonic plague; pneumonic and septicemic plague also respond if recognized and treated early. However, one report stated that patients who had not received adequate therapy for primary pneumonic plague within 18 hours after onset of respiratory symptoms were less likely to survive. Slow growth of the organism at normal incubation temperatures may lead to misidentication by automated systems. OccurrencePlague continues to be a threat because of vast areas of persistent wild rodent infection; contact of wild rodents with domestic rats occurs frequently in some enzootic areas. While urban plague has been controlled in most of the world, human plague has occurred in the 1990s in several African countries that include Botswana, the Democratic Republic of the Congo, Kenya, Madagascar, Malawi, Mozambique, the United Republic of Tanzania, Uganda, Zambia and Zimbabwe. Plague is endemic in China, India, Lao Peoples Democratic Republic, Mongolia, Myanmar and Viet Nam. In the Americas, foci in northeastern Brazil and the Andean region (Brazil, Ecuador and Peru) continue to produce sporadic cases and occasional outbreaks including an outbreak of pneumonic plague in Ecuador in 1998. ReservoirWild rodents (especially ground squirrels) are the natural vertebrate reservoir of plague. Lagomorphs (rabbits and hares), wild carnivores and domestic cats may also be a source of infection to people. Mode of transmissionNaturally acquired plague in people occurs as a result of human intrusion into the zoonotic (also termed sylvatic or rural) cycle during or following an epizootic, or by the entry of sylvatic rodents or their infected eas into human habitat; infection in commensal rodents and their eas may result in a domestic rat epizootic and ea-borne epidemics of bubonic plague. Domestic pets, particularly house cats and dogs, may carry plague infected wild rodent eas into homes, and cats may occasionally transmit infection through bites, scratches or respiratory droplets; cats develop plague abscesses that have been a source of infection to veterinary personnel. The most frequent source of exposure that results in human disease worldwide has been the bite of infected eas (especially Xenopsylla cheopis, the oriental rat ea). Person-toperson transmission by Pulex irritans eas (human ea), is presumed to be important in the Andean region of South America and in other places where plague occurs and this ea is abundant in homes or on domestic animals. Certain occupations and lifestyles (including hunting, trapping, cat ownership and rural residence) carry an increased risk of exposure. In the case of deliberate use plague bacilli would possibly be transmitted as an aerosol. Incubation periodFrom 1 to 7 days; may be a few days longer in those immunized who develop illness. Period of communicabilityFleas may remain infective for months under suitable conditions of temperature and humidity. Bubonic plague is not usually transmitted directly unless there is contact with pus from suppurating buboes. Pneumonic plague may be highly communicable under appropriate climatic conditions; overcrowding facilitates transmission. Preventive measures: the basic objective is to reduce the likelihood of people being bitten by infected eas, having direct contact with infective tissues and exudates, or of being exposed to patients with pneumonic plague. In sylvatic or rural plague areas, the public should be advised to use insect repellents and warned not to camp near rodent burrows and to avoid handling of rodents, but to report dead or sick animals to health authorities or park rangers. Dogs and cats in such areas should be protected periodically with appropriate insecticides. Rat suppression by poisoning (see 9B6) may be necessary to augment basic environmental sanitation measures; rat control should always be preceded by measures to control eas. Collection and testing of eas from wild rodents and their nests or burrows may also be appropriate. After the third booster dose, the intervals can be extended to every 1 to 2 years. Immunization of visitors to epidemic localities and of laboratory and eldworkers handling plague bacilli or infected animals is justiable but should not be relied upon as the sole preventive measure; routine immunization is not indicated for most persons resident in enzootic areas. Live attenuated vaccines are used in some countries; they may produce more adverse reactions, without evidence that they are more protective. Control of patient, contacts and the immediate environment: 1) Report to local health authority: Case report of suspected and conrmed cases universally required by International Health Regulations, Class 1 (see Reporting). Because of the rarity of naturally acquired primary plague pneumonia, even a single case should initiate prompt suspicion by both public health and law enforcement authorities of deliberate use.
The disease picellers to discount colchicine 0.5 mg with mastercard antibiotic used for kidney infection developing countries; protection discount colchicine 0.5 mg with amex antimicrobial kitchen towel, however generic 0.5mg colchicine amex bacteria are the simplest single cells that, is ture varies from malaise, anorexia and nausea to acute lifeincomplete. Side effects of vaccination include pain at the threatening liver failure, which is rare. A live oral vaccine liver must be damaged or destroyed before liver function (strain Ty 21a) is now available, but protection appears to fails. At least six different viruses are referred to as hepatitis Listeriosis viruses (Fig. Other viruses cause hepatitis as part of a dispregnancy and reduced immunity ease syndrome and are dealt with elsewhere. Dramatic Listeria monocytogenes is a Gram-positive coccobaccillus that elevations of serum aminotransferase concentration (alanine is widespread among animals and in the environment. Specic laboratory tests associated particularly with uncooked foods such as pate, for hepatitis A and B viruses have been available for some contaminated milk, soft cheeses and coleslaw. It is likely that years, and tests for others, originally referred to as nonAa large number of organisms must be ingested to cause disnonB viruses are now becoming available. Other viruses causing hepatitis include EpsteinBarr virus (mild hepatitis in 15% of infected adults and adolescents) and rarely herpes simplex virus, while intrauterine infection with rubella or cytomegalovirus causes hepatitis in the newborn. It then tion period between infection and illness is 24 weeks; virus infects liver cells, passing into the biliary tract to reach the is present in feces 12 weeks before symptoms appear and intestine and appear in feces (Fig. Relatively small during the rst week (sometimes also the second and third amounts of virus enter the blood at this stage. The mean incubation period of Rehabilitation Services traced 61 people who had suffered the disease was 29 days (range 1648 days). These individsources of fecal contamination near the oyster beds uals resided in five different states, but 59 of them had included boats with inappropriate sewage disposal systems eaten raw oysters from the same growing areas in Bay and discharge from a local sewage treatment plant that conCounty coastal waters. The oysters had been gathered illetained a high concentration of fecal coliforms. Systemic Infection Initiated in the Gastrointestinal Tract 279 virus ingested hepatitis sewageshellfish filter off shellfish harvested; contaminated water virus particles eaten raw while feeding or partially cooked virus in feces Fig. Common clinical manifestations are fever, anorexia, nausea, vomiting; jaundice is more common in adults. There is no antiviral therapy, but an effective formaldehyde-inactivated vaccine is now available. These do not differ in virulence filaments) in blood; indicates infectivity of blood or chronicity, but are useful in epidemiologic studies. Virus carriers, of which there are about 350 million worldwide, play a major role in transmission. Much of the pathology infectious, often for life, and although continuing liver is immune mediated, for instance attack on infected liver cells damage can cause chronic hepatitis, the damage is often so by virus-specific Tcs. As the first virus-specific of people are more or less likely to become carriers as follows: antibodies are formed there may be a brief prodromal illness People with a more vigorous immune response to the with a rash and arthralgia. This is seen in 1020% of icteric infection clear the virus more rapidly, but tend to suffer a (jaundiced) patients and is due to the formation of immune more severe illness. These are deposited in the skin and joints for There is a marked age-related effect. The immune response slowly becomes effective, virus repli Sex is another factor, with males being more likely to cation is curtailed, and eventually, although sometimes not for become carriers than females. The hosts In countries where infection in infancy and childhood is Hepadnaviruses Hepadnaviruses are also found in woodchucks, ground instance, 30% of woodchucks carry their own type of hepsquirrels and Pekin ducks. In each case the infection peradnavirus and most develop liver cancer by later life. These viruses cells in the spleen, peripheral blood and thymus and in panoften infect non-hepatic cells. Systemic Infection Initiated in the Gastrointestinal Tract 281 common (possibly because there is a high carrier rate in recovery and convalescence, but remains in carriers. One proband as the amount increases it signifies that infectious lem is that up to 10% of normal individuals fail to produce (Dane) particles are also present (Fig. This is prepared from the serum of particle infectious by attaching it to hepatic cells. Antibody to viral protein could then There is no vaccine, but vaccination against hepatitis B be tested for in sera. The virus is excreted in feces and spreads by the to infant; sexual transmission is uncommon. The dischronic active hepatitis ease is generally mild, but is severe in pregnant women with a the incubation period is 24 months, at which stage mild high mortality (up to 20%) involving disseminated intravasdisease occurs in about one in 10 individuals. Virus is often detectable in the eliminated from the body on recovery and there are no carriblood after recovery from the illness, and carriers are a source ers. About 50% of patients develop chronic active hepatitis and 20% progress to cirrhosis. Approximately 510% of hepatitis cases known to be transIf antibody is present it is possible that the virus is also mitted by blood transfusion cannot be attributed to a known present and the patient is infectious, but this is not necessarvirus. Hepatitis F virus (a virus of uncerare much more restricted in their distribution. In Asia, infections with the human liver uke Clonorchis sinensis are acquired by eating sh infected with the metacerParasitic infections affecting the liver carial stage. Juvenile ukes released in the intestine move up An inammatory response to the eggs of the bile duct and attach to the duct epithelium, feeding on Schistosoma mansoni results in severe liver the cells and blood and tissue uids. In heavy infections there damage is a pronounced inflammatory response, and proliferation Liver pathology in parasitic infections is most severe in S. There only a relatively short time in the liver before moving to the may be an association with cholangiocarcinoma, but there is mesenteric vessels, eggs released by the females can be swept little evidence for this in humans. These include species of Opisthorchis (in Asia these trapped eggs is the primary cause of the complex and Eastern Europe) and the common liver uke Fasciola hepchanges that result in hepatomegaly, brosis and the formaatica.
Department of Agriculture; the Department of Defense; the Institute of Medicine; the Dietary Reference Intakes Private Foundation Fund buy cheap colchicine online antibiotic 5 day, including the Dannon Institute and the International Life Sciences Institute generic colchicine 0.5mg without a prescription infection 4 weeks after wisdom teeth removal, North America; and the Dietary Reference Intakes Corporate Donors Fund colchicine 0.5 mg with mastercard antimicrobial effect of chlorhexidine gluconate. Contributors to the Fund include Roche Vitamins Inc, Mead Johnson Nutrition Group, and M&M Mars. The views presented in this report are those of the Institute of Medicine Standing Committee on the Scientific Evaluation of Dietary Reference Intakes and its panels and subcommittes and are not necessarily those of the funding agencies. Library of Congress Cataloging-in-Publication Data Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids / Panel on Macronutrients, Panel on the Definition of Dietary Fiber, Subcommittee on Upper Reference Levels of Nutrients, Subcommittee on Interpretation and Uses of Dietary Reference Intakes, and the Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academys purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. His expertise in protein and amino acid metabolism was a special asset to the panels work, as well as a contribution to the understanding of protein and amino acid requirements. Close attention was given throughout the report to the evidence relating macronutrient intakes to risk reduction of chronic disease and to amounts needed to maintain health. Thus, the report includes guidelines for partitioning energy sources (Acceptable Macronutrient Distribution Ranges) compatible with decreasing risks of various chronic diseases. Thus, although governed by scientific rationales, informed judgments were often required in setting reference values. The quality and quantity of information on overt deficiency diseases for protein, amino acids, and essential fatty acids available to the committee were substantial. Unfortunately, information regarding other nutrients for which their primary dietary importance relates to their roles as energy sources was limited most often to alterations in chronic disease biomarkers that follow dietary manipulations of energy sources. Also, for most of the nutrients in this report (with a notable exception of protein and some amino acids), there is no direct information that permits estimating the amounts required by children, adolescents, the elderly, or pregnant and lactating women. Doseresponse studies were either not available or were suggestive of very low intake levels that could result in inadequate intakes of other nutrients. These information gaps and inconsistencies often precluded setting reliable estimates of upper intake levels that can be ingested safely. The reports attention to energy would be incomplete without its substantial review of the role of daily physical activity in achieving and sustaining fitness and optimal health (Chapter 12). The report provides recommended levels of energy expenditure that are considered most compatible with minimizing risks of several chronic diseases and provides guidance for achieving recommended levels of energy expenditure. Inclusion of these recommendations avoids the tacit false assumption that light sedentary activity is the expected norm in the United States and Canada. With more experience, the proposed models for establishing reference intakes of nutrients and other food components that play significant roles in promoting and sustaining health and optimal functioning will be refined. Also, as new information or new methods of analysis are adopted, these reference values undoubtedly will be reassessed. Many of the questions that were raised about requirements and recommended intakes could not be answered satisfactorily for the reasons given above. Thus, among the panels major tasks was to outline a research agenda addressing information gaps uncovered in its review (Chapter 14). The research agenda is anticipated to help future policy decisions related to these and future recommendations. This agenda and the critical, comprehensive analyses of available information are intended to assist the private sector, foundations, universities, governmental and international agencies and laboratories, and other institutions in the development of their respective research priorities for the next decade. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Arne Astrup, the Royal Veterinary and Agricultural University; George Blackburn, Beth Israel Deaconess Medical Center; Elsworth Buskirk, Pennsylvania State University; William Connor, Oregon Health and Science University; John Hathcock, Council for Responsible Nutrition; Satish Kalhan, Case Western Reserve University School of Medicine; Martijn Katan, Wageningen Agricultural University; David Kritchevsky, the Wistar Institute; Shiriki Kumanyika, University of Pennsylvania School of Medicine; William Lands, National Institutes of Health; Geoffrey Livesey, Independent Nutrition Logic; Ross Prentice, Fred Hutchinson Cancer Research Center; Barbara Schneeman, University of California, Davis; Christopher Sempos, State University of New York, Buffalo; Virginia Stallings, Childrens Hospital of Philadelphia; Steve Taylor, University of Nebraska; Daniel Tome, Institut National Agronomique Paris-Grinon; and Walter Willett, Harvard School of Public Health. The review of this report was overseen by Catherine Ross, Pennsylvania State University and Irwin Rosenberg, Tufts University, appointed by the Institute of Medicine, who were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution. The Food and Nutrition Board gratefully acknowledges the Canadian governments support and Canadian scientists participation in this initiative. This close collaboration represents a pioneering first step in the harmonization of nutrient reference intakes in North America.
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He seemed to order generic colchicine on-line antibiotic how long to work be made of reinforced concrete: he was enormous order 0.5mg colchicine with visa antibiotic treatment for gonorrhea, with hair all over his body except on his head buy generic colchicine 0.5mg on-line good antibiotics for sinus infection, a mustache like a housepainters brush, a voice like a capstan, which would have been his alone, and an exquisite courtesy. Before they sat down to the table he had finished half of the demijohn, and he fell forward onto the tray of glasses and bottles with a slow sound of demolition. Ausencia Santander had to ask Florentino Ariza to help her drag the inert body of the beached whale to bed and undress him as he slept. Then, in a flash of inspiration that they attributed to a conjunction of their stars, the two of them undressed in the next room without agreeing to, without even suggesting it or proposing it to each other, and for more than seven years they continued undressing wherever they could while the Captain was on a trip. There was no danger of his surprising them, because he had the good sailors habit of advising the port of his arrival by sounding the ships horn, even at dawn, first with three long howls for his wife and nine children, and then with two short, melancholy ones for his mistress. Ausencia Santander was almost fifty years old and looked it, but she had such a personal instinc t for love that no homegrown or scientific theories could interfere with it. Florentino Ariza knew from the ships itineraries when he could visit her, and he always went unannounced, whenever he wanted to, at any hour of the day or night, and never once was she not waiting for him. She would open the door as her mother had raised her until she was seven years old: stark naked, with an organdy ribbon in her hair. She would not let him take another step until she had undressed him, because she thought it was bad luck to have a clothed man in the house. This was the cause of constant discord with Captain Rosendo de la Rosa, because he had the superstitious belief that smoking naked brought bad luck, and at times he preferred to put off love rather than put out his inevitable Cuban cigar. On the other hand, Florentino Ariza was very taken with the charms of nudity, and she removed his clothes with sure delight as soon as she closed the door, not even giving him time to greet her, or to take off his hat or his glasses, kissing him and letting him kiss her with sharp-toothed kisses, unfastening his clothes from bottom to top, first the buttons of his fly, one by one after each kiss, then his belt buckle, and at the last his vest and shirt, until he was like a live fish that had been slit open from head to tail. Then she sat him in the living room and took off his boots, pulled on his trouser cuffs so that she could take off his pants while she removed his long underwear, and at last she undid the garters around his calves and took off his socks. Then Florentino Ariza stopped kissing her and letting her kiss him so that he could do the only thing he was responsible for in that precise ceremony: he took his watch and chain out of the buttonhole in his vest and took off his glasses and put them in his boots so he would be sure not to forget them. He always took that precaution, always without fail, whenever he undressed in someone elses house. As soon as he had done that, she attacked him without giving him time for anything else, there on the same sofa where she had just undressed him, and only on rare occasions in the bed. She mounted him and took control of all of him for all of her, absorbed in herself, her eyes closed, gauging the situation in her absolute inner darkness, advancing here, retreating there, correcting her invisible route, trying another, more intense path, another means of proceeding without drowning in the slimy marsh that flowed from her womb, droning like a horsefly as she asked herself questions and answered in her native jargon; where was that something in the shadows that only she knew about and that she longed for just for herself, until she suc cumbed without waiting for anybody, she fell alone into her abyss with a jubilant explosion of total victory that made the world tremble. Florentino Ariza was left exhausted, incomplete, floating in a puddle of their perspiration, but with the impression of being no more than an instrument of pleasure. But then he would wake for no reason in the middle of the night, and the memory of the selfabsorbed love of Ausencia Santander was revealed to him for what it was: a pitfall of happiness that he despised and desired at the same time, but from which it was impossible to escape. One Sunday, two years after they met, the first thing she did when he arrived was to take off his glasses instead of undressing him, so that she could kiss him with greater ease, and this was how Florentino Ariza learned that she had begun to love him. Despite the fact that from the first day he had felt very comfortable in the house that he now loved as if it were his own, he had never stayed longer than two hours, and he had never slept there, and he had eaten there only once because she had given him a formal invitation. He went there, in fact, only for what he had come for, always bringing his only gift, a single rose, and then he would disappear until the next unforeseeable time. But on the Sunday when she took off his glasses to kiss him, in part because of that and in part because they fell asleep after gentle love-making, they spent the afternoon naked in the Captains enormous bed. When he awoke from his nap, Florentino Ariza still remembered the shrieking of the cockatoo, whose strident calls belied his beauty. But the silence was diaphanous in the four oclock heat, and through the bedroom window one could see the outline of the old city with the afternoon sun at its back, its golden domes, its sea in flames all the way to Jamaica. Ausencia Santander stretched out an adventurous hand, seeking the sleeping beast, but Florentino Ariza moved it away. At five oclock, with the sun still high, she jumped out of bed, naked as always and with the organdy ribbon in her hair, and went to find something to drink in the kitchen. But she had not taken a single step out of the bedroom when she screamed in horror. All the rest, the signed furniture, the Indian rugs, the statues and the handwoven tapestries, the countless trinkets made of precious stones and metals, everything that had made hers one of the most pleasant and best decorated houses in the city, everything, even the sacred cockatoo, everything had vanished. All that was left were empty rooms with the four open windows, and a message painted on the rear wall: this is what you get for fucking around. Captain Rosendo de la Rosa could never understand why Ausencia Santander did not report the robbery, or try to get in touch with the dealers in stolen goods, or permit her misfortune to be mentioned again. Florentino Ariza continued to visit her in the looted house, whose furnishings were reduced to three leather stools that the thieves forgot in the kitchen, and the contents of the bedroom where the two of them had been. But he did not visit her as often as before, not because of the desolation in the house, as she supposed and as she said to him, but because of the novelty of a mule-drawn trolley at the turn of the new century, which proved to be a prodigious and original nest of freeflying little birds. He rode it four times a day, twice to go to the office, twice to return home, and sometimes when his reading was real, and most of the time when it was pretense, he would take the first steps, at least, toward a future tryst. He was right: there is no worse enemy of secret love than a carriage waiting at the door. In fact, he almost always left it hidden at his house and made his hawkish rounds On foot so that he would not leave wheel marks in the dust. That is why he evoked with such great nostalgia the old trolley with its emaciated mules covered with sores, in which a sideways glance was all one needed to know where love was. However, in the midst of so many tender memories, he could not elude his recollection of a helpless little bird whose name he never knew and with whom he spent no more than half a frenetic night, but that had been enough to ruin the innocent rowdiness of Carnival for him for the rest of his life. She had attracted his attention on the trolley for the fearlessness with which she traveled through the riotous public celebration. She could not have been more than twenty years old, and she did not seem to share the spirit of Carnival, unless she was disguised as an invalid: her hair was very light, long, and straight, hanging loose over her shoulders, and she wore a tunic of plain, unadorned linen. She was completely removed from the confusion of music in the streets, the handfuls of rice powder, the showers of aniline thrown at the passengers on the trolley, whose mules were whitened with cornstarch and wore flowered hats during those three days of madness. Taking advantage of the confusion, Florentino Ariza invited her to have an ice with him, because he did not think he could ask for anything more. Then he put on a rented cape, and the two of them joined the dancing in the Plaza of the Customhouse, and enjoyed themselves like newborn sweethearts, for her indifference went to the opposite extreme in the uproar of the night: she danced like a professional, she was imagina tive and daring in her revelry, and she had devastating charm.