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Case 15 A 72-year-old man is brought to the emergency room after fainting while in church order eurax 20gm amex acne treatment for men. His wife order online eurax acne ziana, who witnessed the episode order on line eurax acne out-, reports that he was uncon- scious for approximately 5 minutes cheap eurax 20gm visa skin care lines for estheticians. This has never happened to him before, but his wife does report that for the last several months he has had to curtail activi- ties, such as mowing the lawn, because he becomes weak and feels light- headed. His only medical history is osteoarthritis of his knees, for which he takes acetaminophen. He is afebrile, his heart rate is regular at 35 bpm, and his blood pressure is 118/72 mm Hg, which remains unchanged on standing. His chest is clear to auscultation, and his heart rhythm is regular but bradycardic with a nondisplaced apical impulse. Laboratory examination shows normal blood counts, renal function, and serum electrolyte levels, and negative cardiac enzymes. He has experienced decreasing exercise tolerance recently because of weakness and presyncopal symptoms. He should be evaluated for myocardial infarction and structural cardiac abnormalities. If this evaluation is negative, he may simply have conduction system disease as a consequence of aging. The causes are varied, but they all result in transiently diminished cerebral perfusion leading to loss of consciousness. The prognosis is quite varied, ranging from a benign episode in an otherwise young, healthy person with a clear precipitating event, such as emotional stress, to a more serious occurrence in an older patient with cardiac disease. In the latter situation, syncope has been referred to as “sudden cardiac death, averted. Traditionally, the etiologies of syncope have been divided into neurologic and cardiac. However, this probably is not a useful classification, because neu- rologic diseases are uncommon causes of syncopal episodes. Vertebrobasilar insufficiency with resultant loss of consciousness is often discussed yet rarely seen in clinical practice. Seizure episodes are a com- mon cause of transient loss of consciousness, and distinguishing seizure episodes from syncopal episodes based on history often is quite difficult. To fur- ther complicate matters, the same lack of cerebral blood flow that produced the loss of consciousness can lead to postsyncopal seizure activity. Seizures are best discussed elsewhere, so our discussion here is confined to syncope. The only neurologic diseases that commonly cause syncope are disturbances in autonomic function leading to orthostatic hypotension as occurs in dia- betes, parkinsonism, or idiopathic dysautonomia. For patients in whom a definitive diagnosis of syncope can be ascertained, the causes usually are excess vagal activity, orthostatic hypotension, or cardiac disease—either arrhythmias or outflow obstructions. By far, the most useful evaluation for diagnosing the cause of syncope is the patient’s history. Vasovagal syncope refers to excessive vagal tone causing impaired auto- nomic responses, that is, a fall in blood pressure without appropriate rise in heart rate or vasomotor tone. Episodes often are precipitated by physical or emotional stress, or by a painful experience. There is usually a clear precipitating event by history and, often, prodromal symptoms such as nausea, yawning, or diaphoresis. Syncopal episodes also can be triggered by physiologic activities that increase vagal tone, such as micturition, defecation, or coughing in otherwise healthy people. This usually occurs in older men, and episodes can be triggered by turning the head to the side, by wearing a tight collar, or even by shaving the neck over the area. Less commonly, carotid sinus pressure can cause a fall in arterial pres- sure without cardiac slowing. When recurrent syncope as a result of brad- yarrhythmias occurs, a demand pacemaker is often required. Patients with orthostatic hypotension typically report symptoms related to positional changes, such as rising from a seated or recumbent position, and the postural drop in systolic blood pressure by more than 20 mm Hg can be demonstrated on examination. This can occur because of hypovolemia (hem- orrhage, anemia, diarrhea or vomiting, Addison disease) or with adequate cir- culating volume but impaired autonomic responses. The most common reason for this autonomic impairment probably is iatrogenic as a result of antihyper- tensive or other medications, especially in elderly persons. It also can be caused by autonomic insufficiency seen in diabetic neuropathy, in a syndrome of chronic idiopathic orthostatic hypotension in older men, or the primary neuro- logic conditions mentioned previously. Multiple events that all are unwitnessed or that occur only in periods of emotional upset suggest factitious symptoms. Etiologies of cardiogenic syncope include rhythm disturbances and struc- tural heart abnormalities. Certain structural heart abnormalities will cause obstruction of blood flow to the brain, resulting in syncope. Syncope due to cardiac outflow obstruction can also occur with massive pulmonary embolism and severe pulmonary hypertension. Syncope caused by cardiac out- flow obstruction typically presents during or immediately after exertion. Arrhythmias, usually bradyarrhythmias, are the most common cardiac cause of syncope. Prognosis is good, and there is generally no need for pacing unless the patient is symptomatic (ie, bradycardia, syncope, heart failure, asystole >3 seconds). Permanent pacing is indicated in these patients, especially when associated with symptoms such as exercise intolerance or syncope. She apparently recovered spon- taneously, did not exhibit any seizure activity, and has no medical his- tory. She is noted to have some diabetic retinopathy, and she states that she can- not feel her legs. Which of the following is the most useful diagnostic test of his probable condition? A young patient without a medical history and with no seizure activity is unlikely to have any serious problems. This diabetic patient has evidence of microvascular disease, includ- ing peripheral neuropathy, and likely has autonomic dysfunction. He likely has carotid hypersensitivity; thus, careful carotid mas- sage (after auscultation to ensure no bruits are present) may be given in an attempt to reproduce the symptoms. This patient’s bradycardia is severe, probably a result of the infe- rior myocardial infarction. Mobitz type I block has a good prognosis (vs complete heart block), so transvenous pacing is not usually required. Case 16 A 28-year-old man comes to the emergency room complaining of 2 days of abdominal pain and diarrhea. He describes his stools as frequent, with 10 to 12 per day, small volume, sometimes with visible blood and mucus, and preceded by a sudden urge to defecate.

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All facilities and programs providing addiction treatment should be required to have a full-time certified addiction physician specialist on staff to serve as medical director buy eurax overnight delivery acne xyl, oversee patient care and be responsible for all treatment services buy eurax 20 gm lowest price acne 404 nuke. All individual providers * Currently buy eurax visa acne inversa, the provision of such services frequently of patient care in these facilities and is optional buy 20 gm eurax mastercard acne x lanvin. For example, the Joint Commission programs should be required to be licensed currently has voluntary performance measures for in their field of practice and demonstrate hospitals that choose to provide these addiction- mastery of the core clinical competencies. However, hospitals are required to Professionals who are in the process of choose four out of 14 possible core performance measurements sets and may completely avoid those related to addiction care (see Chapter X). Federal and state governments in collaboration with professional associations, accrediting Educate Non-Health Professionals about organizations and other non-profit organizations Risky Substance Use and Addiction focusing on health care quality--such as the * Washington Circle, the National Committee for Require that the topic of risky substance use and addiction be included in the education and training of government-funded professionals who do not provide direct addiction-related services but who come into contact with significant numbers of individuals who engage in risky substance use or who may have addiction. These include, but are not limited to law enforcement and other criminal justice * The Washington Circle is a group of national personnel, legal staff, child welfare and other experts in addiction-related policy, research and social service workers and educators. Substance performance management who seek to improve the use- and addiction-related content should quality and effectiveness of prevention and treatment include: services through the use of performance measurement systems. License Addiction Treatment Facilities as Health Care Providers  Public payers and private health insurance companies should use all available tools-- Federal, state and local governments should including quality assurance measurements, subject all addiction treatment facilities and pay-for-performance contracting and other programs to the same mandatory licensing incentives--to encourage participating processes as other health care facilities. The general medicine field needs to accept  When to seek help and where to turn for that these are legitimate medical conditions for effective intervention and care. The portfolio of the institute also performance and outcomes measures for should include health conditions resulting from research and evaluation. Because of changes made in survey professional associations’ licensing and methodology, time series data are available only certification requirements for individual from 2002. The discharge variables 2009 to addiction treatment programs in include treatment completion, length of stay, facilities that report to individual state substances of addiction, type of services offered, administrative data systems. Rather, it those ages 12 and older who were discharged includes admissions to facilities that are licensed from addiction treatment facilities in 2008. Thus, an individual admitted to treatment twice within a calendar year would be counted as two admissions. Department of Health and Human experts in a broad range of fields relevant to the Services’ Substance Abuse and Mental Health * study. Informants were identified oversampling of hospitals in selected through a literature review, past research, metropolitan areas. When Where informants were amenable, an interview alcohol is the only substance implicated in a guide was used. A relatively even balance of men The National Addiction Belief and and women was sought in each group. Hart Research Associates arranged for and questionnaire was administered by means of a moderated the focus groups and fielded the telephone survey. In each city, one group was composed of respondents without a college education and  +/- 2. A total of 3,663 households answered the phone and attempts were made to * No qualitative differences were found in the responses of these two groups of participants. We received the initial respondents) broke off before the sample frame from the New York State Office interviewer could obtain informed consent. The goal was to complete interviews respondents) stayed on the line and with the director and two staff members at 75 answered the informed consent question. We  Refusal Rate of Informed Consent: Sixty- estimated that we would need to begin with a nine percent (1,595 respondents) agreed to sample of 500 treatment facilities in order to the informed consent question. The obtain the target number of completed remaining 31 percent (704 respondents) interviews. The remaining 18 percent (292 respondents) terminated the Between December 17, 2008 and February 27, survey before it was completed. The survey protocol utilized multiple data collection modalities including telephone, fax and the Internet. Since our goal was 75 The goal of the surveys was to explore the types completed facility surveys, we recruited in of treatment services provided in addiction blocks of 20 from the 224 facilities that treatment facilities and programs in New York, completed the screening instrument. We how performance and outcomes are assessed and exceeded the goal, resulting in a completion the attitudes and beliefs of treatment providers rate of 15. Eleven professional associations agreed to share The following agencies and organizations agreed the link to the survey either via a group e-mail, a either to send an e-mail blast with an embedded posting on their Web site or in an association survey link to their members or to include the newsletter. We collected data on state licensing requirements for each profession, Respondents self-defined as being in “long-term including addiction-related requirements and recovery” (i. The average reported length of being “clean and sober” was Addiction Facility/Program Licensing and 10 or more years. The survey links were open Accreditation Requirements from July 2007 to July 2008. We collected related to the provision of addiction treatment data on requirements pertaining to staff services. In some cases where key information composition and qualifications, provided could not be identified or where requirements services, quality assurance activities and the use were unclear, we called or e-mailed the relevant of patient outcomes data. Because licensing and certification requirements Case Study of Addiction Treatment are found in a wide variety of laws and regulations and can change on a state-by-state in New York basis, findings from this review cannot be guaranteed to be complete and current. The goal of this work was to provide an in-depth look at one state/city parallel * Using the Lexis/Nexis database to supplement information related to state laws and regulations † available on the Internet. Relevant findings from these analyses and illustrative quotes from key informants are incorporated into the report. If so, do you think it requires some type of intervention or treatment for members other than the addict? Q6 When people are looking for help for an addiction problem, who do they usually turn to or where do they go and why? Q7 When someone gets help for an addiction problem, what type of help do they usually receive? Q9 What is your definition of effective treatment for substance abuse or addiction? Q11 Under what conditions does effective treatment of addiction require treatment of co-morbid psychiatric conditions? Q12 What do you think can be done to make treatment more science- or evidence-based? Is evidence from research findings accessible and understandable to providers, as well as to policymakers and advocacy groups? Q14 What do you think stands in the way of people getting quality, effective treatment and of providers offering quality, effective treatment? Q16 Do you think there should be minimum standards of knowledge, skills and/or training for an individual to provide treatment? Coppola, John, Executive Director, New York Association of Alcoholism and Substance Abuse Providers, Inc. Senator Biden * Titles and affiliations represent those at the time of Key Informant participation. Edward, Immediate Past President, American Medical Association Hoffman, PhD, Norman G.

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Increases in mortality rates from suicide and secondary to alcohol and smoking have been 1640 E eurax 20 gm with visa acne 5 days past ovulation. It should be noted that not every expert agrees with the removal of panic disorder from the general body of anxiety cheap eurax 20gm online skin care quotes. Females with panic disorder are more likely to be agoraphobic and to have comorbid depression generic 20 gm eurax acne 4 year old. There are many postulated reasons for this comorbidity: co-occurrence of two common disorders order eurax online acne 1cd-9, overlapping diagnostic criteria, those cases with both groups of symptoms have a unique disorder, panic leads to depression, etc. Compared to the relative of someone who is simply depressed, the relative of a patient who has panic plus depression is at greater risk of developing affective, anxiety, or alcohol abuse problems, although the former relative is also at increased risk for developing anxiety (and panic) disorder. As a generalisation, 1 in 10 people has occasional panic attacks and 2% of people have 1649 panic disorder. Collier (2002) reviewed the interesting possibility that a slightly longer arm of chromosome 15 may cause 1650 panic disorder. Possible candidate genes in the affected gene include those for 1652 three nicotinic acid receptors and the neurotrophin-3 receptor. Based on dreams and ‘screen memories’, a connection with separation anxiety has been proposed. Aschenbrand ea (2003), based on a 7-year longitudinal study, point out that separation anxiety disorder is not synonymous with panic in children and that it does not necessarily continue as adult panic disorder, although they acknowledge that separation anxiety disorder is more common in the children of people with panic disorder. Nevertheless, the separate diagnosis of separation 1653 anxiety disorder persisting into adulthood has been neglected and such a diagnosis in a parent of a child with separation anxiety disorder may be commonplace. Propranolol, haloperidol, and perhaps risperidone more than olanzapine may induce separation anxiety in children whilst the medication is taken. The patient may be anxious about the health of a loved one, become anxious when the partner goes to work, be unable to sleep when a partner is away on a business trip, telephone him constantly, call personally to a partner’s place of work when he cannot be raised by ‘phone, etc. Miller ea (2000) reported no change in resting anxiety levels in panic disorder or normal controls after tryptophan depletion. Nocturnal production of melatonin, a derivative of serotonin, may be increased in panic patients. Transcranial Doppler ultrasonography has shown reduced basilar artery blood flow during hyperventilation in panic disorder patients that may respond to nimodipine, a centrally active calcium channel-blocking agent. There is some evidence for cholinergic hyperactivity in panic disorder: augmented growth hormone response to pyridostigmine challenge. Hypotheses concerning the genesis of panic disorder are outlined and in the diagram. According to Gorman ea,(2000) heritable factors and stressful life events (especially if experienced early in life) may be responsible for the onset of panic disorder. Drug treatment (especially if serotonergic) might desensitise the ‘fear network’ and psychosocial treatments might reduce contextual fear and cognitive misattribution at the level of the prefrontal cortex and hippocampus. McCann ea, 1997) 520 Hippocampus + prefrontal cortex + brainstem behaviour Tx After Klein(1981): Spontaneous unprovoked panic attack leads to Cued panic attacks leads to Anticipatory anxiety leads to Agoraphobia After McNally and Lorenz(1987): It is not misinterpretation of somatic sensations that causes panic, but rather the belief that the sensations per se are dangerous. After Wolpe and Rowan(1988): Anxiety leads to Hyperventilation that causes dizziness + paraesthesiae which, on repetition leads to Conditioned stimuli that can provoke panic attacks After Clark(1988):** Interoceptive or exteroceptive stimulus leads to Perception of threat leads to Apprehensiveness leads to Somatic sensations leads to Misinterpretation of sensations leading to panic attack leads to perception of threat and vicious cycle repeats itself After Klein(1993): Panic disorder is due to excessively sensitive brainstem suffocation alarm After Shear ea(1993): Innate irritability + unsettling parental behaviour leads to Unresolved dependence/independence issues leads to Excess negative affect leads to Increased biological sensitivity if added to Significant stressor leads to Loss of sense of being safe and being in control if added to Strong negative affect leads to First panic attack *Based on animal studies. These patients are often seen by a variety of specialists before being sent to a mental health expert, e. The following symptoms were reported in over 80% of cases in a report by Noyes ea(1987): fearfulness/worry/apprehension, nervousness, palpitations, muscle aches/tension, trembling/shaking, dizziness/imbalance/faintness/lightheadedness, fear of dying/going crazy, and hot/cold sensations. Simple relaxation exercises and respiratory training often fail because the surges of anxiety may come on too quickly to allow conscious control mechanisms to operate; the patient must practice these techniques between episodes so as to become convinced that they can perform them correctly. The patient then has to learn not to assign symptoms to catastrophe such as impending death, loss of control, or madness, but instead to reassign them to a cause of lesser significance. Interoceptive exposure refers to the gradual exposure of a patient to feared physical sensations, repeated exposure leading in turn to habituation. The theory involves assumes difficulty withdrawing from important attachment figures and poor perceived autonomy. The transference is used to promote change and to encourage confrontation of the emotional significance of panic symptoms. The present author’s practice is to advise abstention from alcohol: some patients self-medicate for panic with alcohol, others only panic because they are drinking, and anyway one is unlikely to get anywhere as long as alcohol contaminates the clinical picture. Stimulants, cannabis, and sympathomimetics (as in nasal decongestants) can precipitate panic attacks at any age. Regular aerobic exercise, like running, is superior to placebo but less effective than clomipramine. Alprazolam (originally used in doses up to 4-10 mgs per day in 4 or 5 doses – modern recommendations are 2-4 mgs; O’Shea, 1989 – a therapeutic window of 20-40 nanograms per ml. Not all studies find an effect for alprazolam that is stronger than placebo and there were doubts as to whether any gains from alprazolam last,(Marks ea, 1993) although some authors reported longterm improvement with alprazolam. Patients may be switched from alprazolam to clonazepam by dividing the total daily dose of alprazolam in milligrams to get that for clonazepam. Clonidine may reduce symptoms at the start of treatment 1660 in some cases but its effects wanes over some weeks. There is some preliminary evidence for efficacy for inositol, a natural glucose isomer and a precursor of the intracellular phosphoinositol cycle. Interestingly, research conducted during the early 1980s found that propranolol pretreatment failed to prevent lactate-induced panic attacks. Pharmacotherapy should be continued for a year before consideration is given to possible very slow 1665 tapering, e. Things to consider before deciding to taper pharmacotherapy Duration and severity of panic disorder before treatment? Published complications of panic disorder include peptic ulcer, hypertension, increased mortality from 1666 suicide and cardiovascular disease, and abuse of alcohol and other substances. There is no evidence that 1667 mitral valve prolapse , which is over-represented in panic disorder patients, makes a difference to history, course or response to treatment. However, Coplan ea (1992), in a series of 22 cases, found that treatment for panic disorder improved mitral valve prolapse on the echocardiogram. The direction of causality remains unknown: does panic disorder cause mitral valve prolapse (anxiety places a strain on the heart) or vice versa? Finally, Hayek ea, (2005) in a review article, pointed out that recent studies found no excess of psychiatric symptoms (including panic disorder) in unselected outpatients participating in the Framingham Heart Study. A poor prognosis is associated with female sex, hypochondriasis, comorbid depression, alcohol abuse, personality disorder, interpersonal sensitivity, side-effects of medication, failure to improve with treatment, longer duration of illness (Shinoda ea, 1999) and more severe phobic avoidance (agoraphobia) at baseline. It is said that panic disorder is its opposite,(Pine ea, 1994) with a hypersensitive or false ‘suffocation alarm’ system. The symptoms of hyperventilation are dyspnoea, air 1668 hunger/suffocation, cold extremities, finger and perioral paraesthesiae , tremor, chest pain/palpitation, nausea, abdominal distension, dizziness/fainting, feelings of unreality, and, rarely, tetany. The patient breathes with either an irregular sighing pattern or with a rapid, shallow, regular pattern. Unilateral somatosensory symptoms, often left-sided, may be induced and confuse the clinician. Stage fright (performance or situational anxiety) Some of the symptoms of anxiety are due to alkalosis secondary to hyperventilation.

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This 200 T he Transform ations of Medicine occasionally entailed hum an or animal sacrifice as a means of propitiating the gods order genuine eurax line acne surgery, as purchase eurax 20gm otc skin care products online, for example discount eurax 20gm overnight delivery acne care, in the tradition of some Central American cultures eurax 20 gm without a prescription skin care greenville sc, but m ore im portantly stressed self-sacrifice. Individuals or groups, presumably re­ sponsible for the affliction, subjected themselves to regimens designed to please or pacify the authorities. Most shamans—again I am using the term generically to embrace early healers from many cultures—played two m ajor roles. In their healing role with patients, shamans emphasized the symbolic aspects of healing, including the use of colorful regalia, sacrifices, spitting of blood, and the use o f fire. But since sickness was an event that could be used to instruct the larger community, shamans also organized cultural experi­ ences for the community, often around the sickness of a member. These “group healing ceremonies,” as Jerom e Frank calls them , mixed curative acts, such as pulse read­ ings, with culturally significant rituals. Prescientific medicine, as bizarre as it often appears, was also doggedly pragmatic. Man and nature co­ existed in an uneasy equilibrium that had to be restored before individual cures and community consensus could be achieved. Claude Levi-Strauss characterizes the paradigm this way: The Eras of Medicine 201 That the mythology of the shaman does not correspond to objective reality does not matter. The protecting spirits, the evil spirits, the supernatural monsters and magical mon­ sters are elements of a coherent system which are the basis of the natives’ concept of the universe. What she does not accept are the incomprehensible and arbitrary pains which represent an element foreign to her system but which the shaman, by invoking the myth, will replace in a whole in which everything has its proper place. But this is precisely what the doctor does; it is one o f the dom inant features of m odern medicine. Many factors have contributed to the rise o f today’s medicine; the parceling o f the body into pieces is only one. T he Cartesian thesis that m ind and m atter were divisible drove a wedge between the m ind and the body that persists in medicine today despite its repudiation everywhere else. And as a way of looking at the world, it was seized by medicine as a way of organizing its endeavor. It relied on magical formulations, but also on techniques consistent with observations o f man and nature indigenous to a given tribe or culture. But with the body freed of the larger m an and conceptualized as a machine, medicine at least had a manageable subject—the m etaphor of the body as a machine. T he sham an was a pivotal cultural 202 The Transform ations of Medicine figure who utilized both healing techniques and communal ceremony. But a sham an was not needed to tinker with a machine; what was needed was a mechanic. Although the m etaphor o f man as a machine is over­ worked, it is nonetheless central to an understanding of this period. As Thom as McKeown, an expert on the period, has said: The approach to biology and medicine established during the seventeenth century was an engineering one based on a physi­ cal model. Nature was conceived in mechanistic terms, which lead in biology to the idea that a living organism could be regarded as a machine which might be taken apart and reas­ sembled if its structure and function were fully understood. In medicine, the same concept lead further to the belief that an understanding of disease processes and of the body’s response to them would make it possible to intervene therapeutically, mainly by physical (surgical), chemical, or electrical methods. To think o f man as a machine does aid us in understanding something about bod­ ily function and about m an’s role in the universe, but it does not follow that treating the body as a machine will heal it. Medicine had largely passed beyond pre­ scriptions based on bodily hum ors, but its techniques were still unsophisticated in today’s terms. Bloodletting persisted, cauterization was used, and the use of purgatives was also common. But medicine rem ained outside the body, at least until it was clear that the body could not be understood without an exam ination o f its inner workings any m ore than, today, an automobile engine can be repaired without remov­ The Eras of Medicine 203 ing the hood. His rew ard was nearly universal denuncia­ tion by the church and by the academic world. It took approxim ately another 200 years before the investigation of what went on inside the skin was widely tolerated. And this did not occur until the m etaphor of the body as a machine was firmly planted. A ntiquarian notions such as the bodily hum ours coexisted with observations of actual function. It was now expected that knowledge would be a fund of observations rather than an elaboration of theological propositions. But until Virchow’s Cellular Pathology was published in 1858,11 medicine re­ m ained a tentative art moving alternatively through old wis­ dom and new findings. T he doctor had em erged, but a cohesive theoretical fram ework for medicine had not. T he first public health practitioner was the sham an, whose initiatives were crude, but pragmatic and probably effective. As an illustration, the sham an might direct that a residence contam inated by the illness of a resi­ dent be burned. But these measures, while conceptually consistent with pub­ lic health, were modest com pared to the measures launched in the nineteenth century. As early as 1853 a physician in London, John Snow, linked a cholera epidemic to contami­ nated water in a public water pum p. But it took the genius o f Pasteur, Koch, and others, later in the century, to firmly tie infectious disease to environm ental sources. But in the late nineteenth cen­ tury the idea was startling, and ushered in an entirely new 204 T he Transform ations of Medicine way o f perceiving the environm ent. T he perception of man as a machine also persisted, but the breakthroughs of Pasteur and others modified the m etaphor. Man was still a machine, and disease a functional disorder, but with the rise o f public health it was now conceivable that defects in the machinery could be in­ troduced by a virulent environm ent. Medicine had slowly im proved its wares, but the health of the population had not dem onstrably improved. M aternal mortality rem ained roughly constant, and longevity did not seem to be affected. T he introduction o f public health pro­ grams radically im proved the health o f the population. For example, Pettenkofer dem onstrated that the installation of sanitary sewage systems in Munich led to immediate im­ provements in health status. No longer was health the result o f caprice, aided by the occasionally perceptive physician. Now it was possible to engineer environm ental conditions that dem onstrably en­ hanced the opportunities for health.