By K. Georg. Shippensburg University of Pennsylvania.

For the twelfth century discount flagyl 250 mg online antibiotic young living essential oils, see Donald Matthew buy flagyl 200mg otc antibiotic withdrawal symptoms, The Norman Kingdom of Sicily (Cambridge: Cambridge University Press, ). Drell, ‘‘Family Struc- ture in the Principality of Salerno During the Norman Period, –,’’ Anglo- Norman Studies: Proceedings of the Battle Conference  (): –; and ‘‘Marriage, Kinship, and Power: Family Structure in the Principality of Salerno under Norman Rule, –’’ (Ph. For their part, however, men could not alienate their female relatives’ property without the woman’s permission. Katherine Fischer Drew (Philadelphia: University of Pennsylvania Press, ), esp. Evidence concerning the general legal and social history of women in southern Italy in the central Middle Ages has only recently begun to be collected. See in particular the essays of Patricia Skinner, ‘‘Women, Wills and Wealth in Medieval Southern Italy,’’ Early Medieval Europe  (): –; ‘‘The Pos- sessions of Lombard Women in Italy,’’ Medieval Life  (spring ): –; ‘‘Disputes and Disparity: Women at Court in Medieval Southern Italy,’’ Reading Medieval Studies  (): –; ‘‘Women, Literacy and Invisibility in Southern Italy, –,’’ in Women, the Book and the Godly: Selected Proceedings of the St Hilda’s Conference, , ed. Drell notes some shifts in the role of mundoalds (men who held a woman’s mundium) over the course of the twelfth century (pp. Copho, for example, distinguishes special remedies for noble people at least six times. See Copho, Practica, in Rudolf Creutz, ‘‘Der Magister Copho und seine Stellung im Hochsalerno: Aus M. The essays collected by Judith Bennett and Amy Froide in Singlewomen in the European Past, – (Philadelphia: Universityof Pennsylvania Press, ) have laid out many new avenues for research. Muhammad ibn Ahmad ibn Jubayr, The Travels of Ibn Jubayr, being the chronicle of a mediaeval Spanish Moor concerning his journey to the Egypt of Saladin, [etc. It is not clear whether the reference to noble- women in ¶, which was added later in the development of the Trotula ensemble, comes out of a Salernitan context. David Nirenberg, Communities of Violence: Persecution of Minorities in the Middle Ages (Princeton: Princeton University Press, ), pp. For example, the polymath Adelard of Bath and several English or Anglo- Norman physicians are known to have studied in Salerno; some Salernitan physicians also emigrated to England. Moreover, some of the earliest extant manuscripts of Con- stantinian and Salernitan writings come from England. Burnett, The Introduction of Arabic Learning into England, Panizzi Lectures,  (London: British Library, ), pp. On the specific significance of this English connection to Treatments of Women, see below. The definitive studyof the institutional historyof the school remains Paul Oskar Kristeller, ‘‘The School of Salerno: Its Development and Its Contribution to the His- tory of Learning,’’ Bulletin of the History of Medicine  (): –; reprinted in Ital- ian translation with further revisions as Studi sulla Scuola medica Salernitana (Naples: Istituto Italiano per gli Studi Filosofici, ). See also Vivian Nutton, ‘‘Velia and the School of Salerno,’’ Medical History  (): –; and ‘‘Continuity or Rediscovery: The City Physician in Classical Antiquity and Mediaeval Italy,’’ in The Town and State Physician in Europe from the Middle Ages to the Enlightenment, ed. My thanks to Francis Newton for informing me of his findings on the early date of Alfanus’s translation of Nemesius (personal communication, June ). His reli- gion of birth is of less import for this story than his native language. On Constantine and his oeuvre, see Bloch, Monte Cassino, : –, –, and : –; and most recently the essays in Constantine the African and ‘Alī ibn al- ‘Abbās al-Magˇūsī: The ‘‘Pantegni’’ and Related Texts, ed. On the intellectual culture of Monte Cassino, see Newton, Scriptorium and Library. Green, ‘‘Constantinus Africanus and the Con- flict Between Religion and Science,’’ in The Human Embryo: Aristotle and the Arabic  Notes to Pages – and European Traditions, ed. Wack, Lovesickness in the Middle Ages: The ‘‘Viaticum’’ and Its Commen- taries (Philadelphia: University of Pennsylvania Press, ); Gerrit Bos, ‘‘Ibn al-Jazzār on Women’s Diseases and Their Treatment,’’ Medical History  (): –; and idem, Ibn al-Jazzār on Sexual Diseases and Their Treatment, Sir Henry Wellcome Asian Series (London: Kegan Paul, ). Jordan, ‘‘Medicine as Science in the Early Commentaries on ‘Johan- nitius,’ ’’ Traditio  (): –; idem, ‘‘The Construction of a Philosophical Medi- cine: Exegesis and Argument in Salernitan Teaching on the Soul,’’ Osiris,dser. By the third quarter of the twelfth century, Galen’s Ars medendi was added to the collection as well. Brian Lawn, The Salernitan Questions: An Introduction to the History of Medieval and Renaissance Problem Literature (Oxford: Clarendon Press, ); The Prose Salerni- tan Questions (London: British Academy/Oxford University Press, ). See George Washington Corner, Anatomical Texts of the Earlier Middle Ages (Washington, D. Tips on practitioner-patient relations did not always conform to the spirit of the Hippocratic Oath. In discussing sanious flux from the womb, Master Salernus bru- tally observes, ‘‘Sometimes it happens that after their cure patients remain ungrateful toward the physician. Therefore, let them be given cut alum with any kind of cooked food so that they are afflicted once again. For if alum is taken, a lesion will necessarily be generated in some part of the body and they will fall sick again’’ (Catholica Magistri Salerni,inMagistri Salernitani nondum editi, ed. Dietlinde Goltz, Mittelalterliche Pharmazie und Medizin (Stuttgart: Wissen- schaftliche Verlagsgesellschaft, ), pp. Besides the gynecological sections of the works just mentioned, the only other gynecological materials of Salernitan origin that I have discovered arewhat seems to be an excerpt from an unidentified Practica, a brief tract on infertility, and a collection of recipes drawn from a varietyof sources.

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Amphetamineandderivatives(includingecstasy)arethe 1 Seizures are treated with diazepam or lorazepam generic 400mg flagyl mastercard antibiotic ear drops. Chapter 15: Alcohol and drugs of abuse 525 Pathophysiology 1 Seizures and agitation are treated with diazepam or Amphetamines are stimulant drugs with cardiovascular flagyl 200 mg line antibiotic resistance assay, lorazepam. Multi- 2 Hypertension should be treated with diazepam or ple doses, taken to maintain euphoria, can lead to intox- if this is ineffective, intravenous glyceryl trinitrate ication, and feelings of anxiety and paranoia. The excre- tion of amphetamine depends on urine pH – acid urine increases its clearance. Ecstasy abuse Definition Clinical features Ecstasy is a semi-synthetic derivative of amphetamine Physical effects of an amphetamine-intoxicated state in- with hallucinogenic properties. A history should be taken of re- usually comes in tablets or capsules, which may have centandpreviousrecreationaldruguse,includingmeth- logos or pictures on them. Occasionally it is and social history should be taken, as well as a medical found in a powder form that is smoked or snorted. Incidence/prevalence Complications Ecstasy use continues to rise, doubling in the last 5 Medical complications include seizures, coma, tach- years. Acute ecstasy, with rates approaching 30% in university stu- hepatic failure has been reported. There have been over 200 deaths from the drug in tions include paranoia, eating disorders, hallucinations 15 years. If physical side-effects highly variable, but in addition idiosyncratic responses are present, U&Es, liver function tests, creatine kinase appear to occur, both in naıve and chronic users. Clinical features r Effects begin within an hour and usually last 4–6 Management hours, but may persist for 48 hours with very high In more than mild toxicity, patients should have cardiac doses. Increasedthirstcanbemarked,suchthatex- 5 Metabolic acidosis should be corrected with sodium cessive water intake occurs, leading to hyponatraemia. Mood effects are 6 Narrow complex tachycardias are treated with intra- of euphoria, and ecstasy is unique in its ability to make venous β-blockers. A psychiatric and social his- Overview of acute poisoning tory should be taken, as well as a medical history and examination. Definition Acute poisoning may result from accidental self- ingestion, deliberate self-harm or medical error. Complications Deaths: These appear to be due to cardiac arrhythmias, fulminant liver failure and neuroleptic malignant syn- Incidence/prevalence drome, which may cause acute renal failure, dissemi- Common presentation to A&E, commonest cause of nated intravascular coagulation and metabolic acidosis. Neuropsychiatric complications include memory and concentration loss, insomnia, hallucinations and flash- Age backs. Aetiology Many different substances are involved in poisoning, es- Management pecially in children (see Table 15. In severe toxicity, initial management includes ensuring aclear airway, and ventilation if needed. Clinical features 1 All patients should have cardiac, pulse, blood pressure Acutepoisoningshouldbeconsideredinanypatientpre- and temperature monitoring. A full physical examination glyceryl trinitrate, but in refractory hypertension con- should be made. Principles of management: Other neurological features include altered behaviour, r Reduction of absorption by emptying the stomach seizures, hallucinations, motor disturbances. However, r Cardiovascular system: Altered heart rate, arrhyth- lavage or induced emesis is contraindicated following mias, blood pressure instability. The patient must have an intact cough reflex dice, vomiting and diarrhoea, alcohol may be smelt or a cuffed endotracheal tube to protect the airway. Alternatively activated charcoal is useful for certain r Eyes: Miosis (constriction of the pupil is seen with drugs, ideally within 4 hours of ingestion dependent opiates and organophosphates) or mydriasis (dilation on the drug. Following an accidental These will depend on the presentation and the availabil- overdose social circumstances need to be considered ity of a reliable history. Patients presenting fol- mayhavetobeinvestigatedandmanagedasanacutecon- lowing deliberate ingestion require a psychiatric eval- fusional state or coma. Appropriate investigations may uation prior to discharge in order to assess their risk include of further self-harm and to identify and manage any r plasma paracetamol and salicylate levels. Accidental or deliberate overdose of paracetamol, caus- r blood gases to detect respiratory failure or metabolic ing liver damage. Complications Incidence These depend on cause and clinical state but may include Currently the commonest drug used for deliberate over- hypothermia, rhabdomyolysis and convulsions. In significant over- dose a prothrombin time, liver and renal function tests and a lactate should be checked and repeated at 24 hours. P-450 Mixed function oxidase Prothrombin time measured 24 hours post ingestion is the best marker for liver damage.

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But by virtue of the nature of the catastrophe the population was fortunately widely spread and overtime there was little competition for resources and there had been plenty of supplies to forage from purchase 250mg flagyl mastercard antimicrobial quaternary ammonium salts. Access to the valley from the high end was very difficult and they had destroyed the single road access making it almost impossible buy flagyl 400 mg fast delivery antibiotic resistant infections, except for the very determined person on foot – and even then the almost invisible paths and steep hillsides and cliffs made passage very difficult. The main access was at the bottom of the valley and was across a bridge over the confluence of three rivers from neighbouring valleys and there own, which was deep and fast moving. So while early on there had been several attacks by small groups on foot, they had never had to deal with the motorized attacks they had heard about from some of the other nearby communities. She was shown into the house by Ralph Hanson; it only took a look from the bedroom door to tell that Sue was pretty sick. Alex turned back to the boy and told him to go back down to the village and get someone to bring up a cart. She knelt by the bed and simultaneously began both reassuring the sick woman and taking a history. The blocks rapidly fell into place - Sue had missed her period 2 weeks ago and had just been building up the courage to tell her husband and boys. She had developed colicky abdominal pain yesterday and this morning it had got much worse. Her hands felt cold to touch and she had a rapid thready pulse at 125, the lower half of her belly was rigid and extremely tender. She didn’t really know where to start, Sue needed surgery, and that wasn’t an option. She drew a iv cannula from her bag - it wasn’t actually a cannula - it was the needle from an old cannula - bleached, boiled and sharpened - as sterile as possible - gone where the plastic cannulas - she was back to leaving the metal needles in veins. Sue was lean and muscular and despite her blood loss, several veins popped up as she applied the tourniquet and Alex easily cannulated her. She reached into her bag and pulled out a small jar of coarse brown crystals, a bottle of sterile water, a 10 ml glass syringe, and needles and began the process of making up some heroin. She had a basic idea of the process from her university chemistry and combined with a bit of street knowledge - she had had a go. She had been at medical school at the time, and she remembered talking in clinical chemistry about how they had been extracting the heroin - it was amazingly easy. So now she had a small jar a granular black powder - it probably wasn’t that pure – mostly heroin – but with a small mix of the assorted other opiates and alkaloids found in the poppy. On the few occasions she had used it, it had been very effective - a little trial and error with the dosing - but effective. The main problem now was sterility and removing all the insoluble rubbish - she had adopted - 205 - Survival and Austere Medicine: An Introduction basically the same techniques the addicts had used – but hopefully slightly more sterile - dissolve it in distilled water, filter it as best she could – she had a small supply of cigarette filter paper she had salvaged for the purpose and then heated it to sterilize it. Not perfect by any means, but like everything else in her world now – near enough frequently had to be good enough. But over the next few minutes, her moaning settled and she seemed more comfortable. There was some down in the clinic, but they were too cumbersome to cart around in her medical backpack. The boy reappeared, in a surprisingly short period of time, with one of the farmers from the village and his horse and cart (really a cut down car with a removed engine and a substituted horse) and they half carried and half walked Sue to the back bed of the cart. They moved off slowly down the valley in the cart, with Sue moaning softly as they moved over the broken tar sealed road, Alex again was trying to think what to do next. Always she arrived at the same conclusion – that while setting fractures and perhaps performing an amputation might be possible, she wasn’t ever going to be able to perform open abdominal surgery – and anyone who needed it was going to die. But now faced with Sue Hanson, lying there in front of her, it didn’t seem so black and white anymore. The first 500mls of normal saline had nearly run through, and Sue’s heart rate had come down and the volume of her pulse seemed stronger. Although this didn’t bother her overly, while Sue was still bleeding from her ruptured ectopic she didn’t want to push her blood pressure up anyway – it would just pop what clot might have formed and encourage more bleeding – more the moment, as long as she had a radial pulse and was awake – that was enough – she didn’t need litres of fluid – she needed an operation. The problem had been how to manufacture it and keep it sterile using a pretty rudimentary set-up. Despite the devastating nature - 206 - Survival and Austere Medicine: An Introduction of the “strike”, they hadn’t been completely driven back to the Stone Age, and while she didn’t have access to proper laboratory equipment, early on in there foraging they had striped the county school of much of its science equipment. This had meant that she had a good number of flasks, beakers, test tubes, and bungs and a small glass condensing coil – most useful of all was an old-style hanging scale, with weights for 1-100gms. This motley collection of equipment had enabled her to produce the heroin and also produce small batches of intravenous fluids. Alex had enlisted Tom, the community brewer – he had over the years established a successful little beer brewery and also a still for making various spirits – on which he also made her high proof medical alcohol. His knowledge of brewing and distilling had been and still was vital in her primitive pharmaceutical production. They had first double distilled water to try and get rid of as many impurities as possible. To this they had added the carefully measured out salt – almost certainly not 100% Sodium Chloride – but hopefully pretty pure.

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And if it does not rupture let it be opened with a lancet flagyl 200 mg online bacteria ulcer, and press out a little in the beginning lest by a sudden evacuation it becomes bad discount flagyl 250mg overnight delivery antibiotics for uti for sale, and each day apply a piece of lint twice or three times smeared with egg yolk. For this cleans every fistula and makes it become necrotic, as long as it is not between any bones. On Foul-Smelling Sweat [] There are some women who have sweat that stinks beyond measure. For these we prepare a cloth dipped in wine in which there have been boiled leaves of bilberry, or the herb itself or the bilberries themselves. Accipe pulegium, policariam, quatuor frondes lauri, et bullianta in aqua, et facias eam sedere in aqua ista, et postb fac de omni- bus fumigium. On Treatments for Women  On Swelling of the Vagina [] For swelling of the vagina. Take pennyroyal, fleabane, and four fronds of laurel, and boil them in water, and you should make her sit in this water, and afterward make a fumigation from all these [herbs]. For Antlike Itching and Itch-Mites [] For antlike itches and itch-mites wherever they might be in the body, especially in the face and on the forehead, we mix grain with wine, and with a powder of frankincense applied in the manner of a plaster, we place it on the [afflicted] spot. On Pain of the Eyes [] For pain of the eyes, take marsh mallow, the herb of violets, tips of bramble, dried roses, vervain, and sermountain. OnW eboftheEye [] If there is a web in the eye, take conch and frankincense and burn them. Take two parts of aloe, and as much frank- incense and plaster of Paris as of the aloe; pulverize them finely and prepare them with fresh animal grease and anoint the place. On Cancer of the Nose [] For cancer of the nose, take lungwort, sage, Greek tar, wild garlic, and ‘‘blacking,’’ that is, earth of the countryside,45 and pulverize them all equally. Et cum exierit de balneo, pista maluam,e arthimesiam, camphoram, et eas pistatas in olla calefacias, et informa magdaleones cum oleo laurino uelf pulegino pauco, et suppone. Tunc accipe tribu- los marinos et coque in aqua marina uelb salsa, et [vb] fumiga pedes sepe, et post fumigium cum fomentumc erit tepidum, lauabis pedes. Postea accipe semen urtice et cornu cerui, et da puluerem inde factum ad bibendum cum uino. Afterward, grind root of delicate willow and root of madder, and give the juice to the patient with wine. Cook all these herbs in water thoroughly, and make the patient sit in it up to her breasts. And when she exits from the bath, pound marsh mal- low, mugwort, and camphor, and warm these pounded things in a pot, and make lozenges with laurel oil or a little pennyroyal oil, and insert them as a suppository. On Swelling of the Feet [] Sometimes it happens that the feet are swollen due to pain of the womb. Then take sea brambles and cook them in sea- or saltwater, and fumigate the feet often. And after the fumigation, when the mixture has become lukewarm, you will wash the feet. Afterward, take nettle seed and buck’s-horn plantain, and give a powder made of this to drink with wine. Accipe paleam auenea et combure in cineres, post apponatur aqua calida quantum patiens sustinere poterit, et intus teneat pedes quous- que infrigidentur. Accipe pinguedinem anguillarum recentium que apparet post decoctionem illarum, et [rb] succum caprifolii, et barbe Iouis, et ouorum formicarum plenam palmam, tere et cola,b et hec omnia simulc cum oleo misceanturd et decoquantur. On Treatments for Women  [On Cutting the Umbilical Cord] [] When the umbilical cord of the child is cut, you should say as follows, holding the stump extended: ‘‘Jesus Christ is dead, he was pierced by the lance, and he took no thought of any ointment or of his pain or of any unguent. On Itch-Mites of the Hands and Feet [] For extracting the worm from the hands and the feet, that is, the itch- mite, which in English is called degge,47 take a heated brick and any kind of vessel full of water, and afterward let henbane seed be placed upon the burning brick. And let the patient hold her feet above the smoke, and you will see the worms falling into the water just like hairs. Afterward let there be applied water as warm as the patient is able to stand it, and let her leave her feet there until they have become cold. Then let it be strained so that none of the water remains, and let the ashes be squeezed well so that the water goes out, and let them be separated bit-by-bit, and there will be found worms just like threads [extracted] by the smoke of the henbane. And in water as hot as she is able to stand it let the limb of the patient be placed, and the worms will come out; afterward let the place be healed just like any other wound. Take the fatty residue of fresh eels which appears after cooking them, and juice of honeysuckle, and houseleek, and a palmful of ants’ eggs; grind them and strain them. After the cooking, let vinegar be added to it so that it might be the more penetrating, or wine as suffices. And pour it into the healthy ear and stop up the afflicted one, and let [the patient] lie upon the ¶a.

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