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The drama of Florentino Ariza while he was a clerk for the River Company of the Caribbean was that he could not avoid lyricism because he was always thinking about Fermina Daza medicine engineering septra 480 mg for sale, and he had never learned to write without thinking about her medicine guide trusted septra 480mg. Later 9 medications that cause fatigue discount generic septra canada, when he was moved to other posts treatment eczema generic septra 480 mg otc, he had so much love left over inside that he did not know what to do with it treatment wasp stings buy cheap septra, and he offered it to unlettered lovers free of charge treatment 1st degree burn order generic septra on-line, writing their love missives for them in the Arcade of the Scribes. He would take off his frock coat with his circumspect gestures and hang it over the back of the chair, he would put on the cuffs so he would not dirty his shirt sleeves, he would unbutton his vest so he could think better, and sometimes until very late at night he would encourage the hopeless with letters of mad adoration. From time to time he would be approached by a poor woman who had a problem with one of her children, a war veteran who persisted in demanding payment of his pension, someone who had been robbed and wanted to file a complaint with the government, but no matter how he tried, he could not satisfy them, because the only convincing document he could write was a love letter. He did not even ask his new clients any questions, because all he had to do was look at the whites of their eyes to know what their problem was, and he would write page after page of uncontrolled love, following the infallible formula of writing as he thought about Fermina Daza and nothing but Fermina Daza. After the first month he had to establish a system of appointments made in advance so that he would not be swamped by yearning lovers. His most pleasant memory of that time was of a very timid young girl, almost a child, who trembled as she asked him to write an answer to an irresistible letter that she had just received, and that Florentino Ariza recognized as one he had written on the previous afternoon. He answered it in a different style, one that was in tune with the emotions and the age of the girl, and in a hand that also seemed to be hers, for he knew how to create a handwriting for every occasion, according to the character of each person. He wrote, imagining to himself what Fermina Daza would have said to him if she had loved him as much as that helpless child loved her suitor. He categorized all the imaginable situations in which he and Fermina Daza might find themselves, and for all of them he wrote as many models and alternatives as he could think of. When he finished, he had some thousand letters in three volumes as complete as the Covarrubias Dictionary, but no printer in the city would take the risk of publishing them, and they ended up in an attic along with other papers from the past, for Transito Ariza flatly refused to dig out the earthenware jars and squander the savings of a lifetime on a mad publishing venture. Years later, when Florentino Ariza had the resources to publish the book himself, it was difficult for him to accept the reality that love letters had gone out of fashion. When he returned from his voyage along the river, he still saw some of them in the hope of dimming the memory of Fermina Daza, he played billiards with them, he went to their dances, he allowed himself to be raffled off among the girls, he allowed himself to do everything he thought would help him to become the man he had once been. As indifferent and irregular as he had been until then regarding food, that was how habitual and austere he became until the end of his days: a large cup of black coffee for breakfast, a slice of poached fish with white rice for lunch, a cup of cafe con leche and a piece of cheese before going to bed. He drank black coffee at any hour, anywhere, under any circumstances, as many as thirty little cups a day: a brew like crude oil which he preferred to prepare himself and which he always kept near at hand in a thermos. He was another person, despite his firm decision and anguished efforts to continue to be the same man he had been before his mortal encounter with love. Winning back Fermina Daza was the sole purpose of his life, and he was so certain of achieving it sooner or later that he convinced Transito Ariza to continue with the restoration of the house so that it would be ready to receive her whenever the miracle took place. They made a reception room where the bedroom had been, on the upper floor they built two spacious, bright bedrooms, one for the married couple and another for the children they were going to have, and in the space where the old tobacco factory had been they put in an extensive garden with all kinds of roses, which Florentino Ariza himself tended during his free time at dawn. The only thing they left intact, as a kind of testimony of gratitude to the past, was the notions shop. The back room where Florentino Ariza had slept they left as it had always been, with the hammock hanging and the writing table covered with untidy piles of books, but he moved to the room planned as the conjugal bedroom on the upper floor. The plain whitewashed walls were rough and unadorned, and the only furniture was a prison cot, a night table with a candle in a bottle, an old wardrobe, and a washstand with its basin and bowl. But that was also the period when Transito Ariza manifested the first symptoms of her incurable disease. At first it seemed she was growing deaf, but it soon became evident that her memory was trickling away. And so she liquidated her pawn business, the treasure in the jars paid for completing and furnishing the house, and still left over were many of the most valuable old jewels in the city, whose owners did not have funds to redeem them. During this period Florentino Ariza had to attend to too many responsibilities at the same time, but his spirits never flagged as he sought to expand his work as a furtive hunter. After his erratic experience with the Widow Nazaret, which opened the door to street love, he continued to hunt the abandoned little birds of the night for several years, still hoping to find a cure for the pain of Fermina Daza. But by then he could no longer tell if his habit of fornicating without hope was a mental necessity or a simple vice of the body. His visits to the trans ient hotel became less frequent, not only because his interests lay elsewhere but because he did not like them to see him there under circumstances that were different from the chaste domesticity of the past. Nevertheless, in three emergency situations he had recourse to the simple strategy of an era before his time: he dis guised his friends, who were afraid of being recognized, as men, and they walked into the hotel together as if they were two gentlemen out on the town. Yet on two of these occasions someone realized that he and his presumptive male companion did not go to the bar but to a room, and the already tarnished reputation of Florentino Ariza received the coup de grace. At last he stopped going there, except for the very few times he did so not to catch up on what he had missed but for just the opposite reason: to find a refuge where he could recuperate from his excesses. No sooner did he leave his office at five in the afternoon than he began to hunt like a chicken hawk. He picked up serving girls in the parks, black women in the market, sophisticated young ladies from the interior on the beaches, gringas on the boats from New Orleans. He took them to the jetties where half the city also went after nightfall, he took them wherever he could, and sometimes even where he could not, and not infrequently he had to hurry into a dark entryway and do what he could, however he could do it, behind the gate. The lighthouse was always a blessed refuge in a storm, which he evoked with nostalgia in the dawn of his old age when he had everything settled, because it was a good place to be happy, above all at night, and he thought that something of his loves from that time flashed out to the sailors with every turn of the light. So that he continued to go there more than to any other spot, while his friend the lighthouse keeper was delighted to receive him with a simpleminded expression on his face that was the best guarantee of discretion for the frightened little birds. There was a house at the foot of the tower, close to the thunder of the waves breaking against the cliffs, where love was more intense because it seemed like a shipwreck. But Florentino Ariza preferred the light tower itself, late at night, because one could see the entire city and the trail of lights on the fishing boats at sea, and even in the distant swamps. He distrusted the sensual type, the ones who looked as if they could eat an alligator raw and tended to be the most passive in bed. The type he preferred was just the opposite: those skinny little tadpoles that no one bothered to turn around and look at in the street, who seemed to disappear when they took off their clothes, who made you feel sorry for them when their bones cracked at the first impact, and yet who could leave the man who bragged the most about his virility ready for the trashcan. Ausencia Santander had had a conventional marriage for twenty years, which left her with three children who had married and had children in turn, so that she boasted of being the grandmother with the best bed in the city. It was never clear if she had abandoned her husband, or if he had abandoned her, or if they had abandoned each other at the same time, but he went to live with his regular mistress, and then she felt free, in the middle of the day and at the front door, to receive Rosendo de la Rosa, a riverboat captain whom she had often received in the middle of the night at the back door. Without giving the matter a second thought, he brought Florentino Ariza to meet her. He also brought a demijohn of home made aguardiente and ingredients of the highest quality for an epic sancocho, the kind that was possible only with chickens from the patio, meat with tender bones, rubbish-heap pork, and greens and vegetables from the towns along the river. Nevertheless, from the very first, Florentino Ariza was not as enthusiastic about the excellence of the cuisine or the exuberance of the lady of the house as he was about the beauty of the house itself. He liked her because of her house, bright and cool, with four large windows facing the sea and beyond that a complete view of the old city. He liked the quantity and the splendor of the things that gave the living room a confused and at the same time rigorous appearance, with all kinds of handcrafted objects that Captain Rosendo de la Rosa brought back from each trip until there was no room left for another piece. On the sea terrace, sitting on his private ring, was a cockatoo from Malaya, with unbelievable white plumage and a pensive tranquillity that gave one much to think about: it was the most beautiful animal that Florentino Ariza had ever seen. 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. 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. 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. 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. When he awoke from his nap, Florentino Ariza still remembered the shrieking of the cockatoo, whose strident calls belied his beauty. Ausencia Santander stretched out an adventurous hand, seeking the sleeping beast, but Florentino Ariza moved it away. 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.

Reduce To use the Magnification controls: To reduce the magnification: Windows: 1 medicine hat news discount septra. In the the reduction in magnification appears in the dialog box that appears symptoms joint pain and tiredness purchase septra online now, type a value and click Magnification drop-down list medicine express buy septra 480 mg with visa. Windows Macintosh You can reduce the magnification until the entire page fits on the screen medications ibs septra 480mg with mastercard. In particular medicine januvia purchase septra us, you can use a selection tool to rearrange the drawing in order to take better advantage of the space available treatment zygomycetes purchase online septra. Using Rulers You can use the rulers to position objects a measured Ruler guides also appear when you drag selected distance away from some reference point or create objects. With this bracketing the ruler are set in the Preferences dialog box, where you can quickly establish the height and width of the you have the choice of inches, centimeters or points. Ruler Guides A check mark appears next to the Show Rulers command, and the rulers appear along the top and left edges of a document window. Using the Crosshair Use the Crosshair to align objects relative to each As you move the pointer, Ruler Guides appear other, and to space objects a consistent distance on each ruler, indicating the position of the apart. In either case, if a bond or side of the object is parallel to one of the axis, it disappears when it is exactly positioned over a Crosshair axis. Drag the second object to the Crosshair axis or grid line and align it to the first. You can also move selected objects in small increments to align them with the Crosshair using You can also show the Rulers while the Crosshair the Arrow keys available on some keyboards: are displayed so that you can see the unit measurement associated with each of the divisions To move 1 point in the direction of an Arrow key: on the Crosshair axes. The selected objects move so that the center of the Selection rectangle is positioned at the If you select only part of a structure or group center of the page. Use the Align commands to align objects relative to Distributing Objects each other. Use the distribute commands to distribute objects horizontally or vertically and at an equal distance apart. For reactants and products with different shapes, select the parts of the objects to distribute. On the Object menu, point to Distribute, and then choose Vertically or Horizontally. The upper, lower, right, and left positions of objects in your selection remain unchanged. Tool Send to Back Tables created with the Table tool are containers for drawings and data. To place a structure in a table, To place one object behind another within a layer: you can draw it directly in the table, or copy or drag 1. In the Setting section, click the borders to which you want to apply the settings. ChemDraw allows you to create tables of text using the Tab key with the Text tool. A caption text box appears exactly aligned under the first caption positioned exactly 20 2. Click in a document window where you want points below the first caption in the first row. The movement is constrained to the X-axis or Y-axis Shift constrains the movement to the Y-axis to maintain the column alignment. Shift+Alt+drag or Shift+Option+drag to To move within an existing table: create a copy of the caption and position it in the empty space you created. To fill in the inserted row with caption text: Alternatively, you can use the following key combinations: 1. Press Tab to move to the second caption in the right Option+Tab (Macintosh) inserted row, and so on. Select the objects to remove with a selection ChemDraw and documents created using other tool. Clipboard, drag and drop, object embedding, and the selected objects are placed on the clipboard file formats. If a ChemDraw document contains fonts that are not Pasting available on a particular computer, they are To paste the contents of the Clipboard into a substituted with fonts that are available. ChemDraw Documents the contents of the clipboard are placed in the center of the active document. You can use the clipboard or the drag-and-drop If the Clipboard contains ChemDraw structures, the feature to transfer ChemDraw pictures to other pasted information is scaled to the settings in the ChemDraw documents. If you are Then Copying using To place a copy of a ChemDraw drawing on the Windows From the desktop, click Start, point clipboard: to Programs, point to Accessories, and then choose the Clipboard 1. A copy of the selected objects is placed on the Macintosh From the Edit menu, choose Show Clipboard. Drag the selection out of the ChemDraw into another application by the same procedure. You can use the drag-and-drop feature to copy To use the contents of a clipping or scrap file in a objects to place in other documents. To use this document: feature in other applications, they must support drag-and-drop. The selection is copied to the destination When you transfer ChemDraw objects using the ChemDraw document. Clipboard or drag and drop from one ChemDraw document (the source document) to another To drag and drop a selection to another application: ChemDraw document (the destination document), the objects are automatically scaled to match the 1. Select an object or structure in a ChemDraw document settings of the destination document. You can also use the drag-and-drop feature to create clipping files (Macintosh) or scrap files (Windows). The font size of the caption can be any size and is not related to the Any resized bond in the source document is scaled setting in the Settings dialog box. This scaling process maintains For example, If the source document has a fixed the source document proportions in the destination length of 1. When the All objects that are not affected by settings in the benzene ring is pasted into the destination Document Settings dialog boxes, such as arrows and document, the bonds are scaled by a factor of 2 to a boxes, are scaled to maintain the same proportions final bond length of 3. With the exception of the foreground and Atom Labels background color, the other colors present in the Atom labels are scaled the same way as bonds. One or two atom labels background color in the destination document is in the source document are resized to 8 points, a unchanged, and all objects colored using the ratio of 8:16 or a scale factor of 0. The destination foreground color are changed to match the document has an atom label font size is set to 14 foreground color in the destination document. When the atom label is pasted into the destination document, the font size is scaled by a factor of 0. From the following table, determine the versions of the ChemDraw software between which you want to transfer documents and then follow the appropriate instructions. If a font in the transferred document is not available, ChemDraw substitutes fonts for those that are available on the To change the settings in the destination document new platform. Transferring from Macintosh to All of the settings in the destination document Windows are changed to match those of the source To be able to open a ChemDraw file created on the document. All of the colors in the Color Palette Macintosh in Windows, follow the instructions for of the destination document are changed to the appropriate versions shown in the table below. Transferring Files to ChemDraw/Plus When a drawing is transferred from ChemDraw into 3. In the Open dialog box, select the graphic and Inserting Reference Numbers click Open. The first reference is inserted as the number 1, each subsequent number is added sequentially. If you have different types of reference text, you are prompted to choose which type to continue the sequence. After you have reference numbers associated with your structures, you can add cross-references to other structures. Transferring PostScript (Macintosh) To obtain the highest quality drawings possible on a To edit the reference number: PostScript printer, ChemDraw creates both a screen 1. Double-click the structure associated with the representation and a PostScript representation of reference. With the ChemDraw Text tool, edit the including most Apple LaserWriter printers, use reference. Importing and Exporting To deselect the PostScript preferences: There are two ways to transfer ChemDraw drawings 1. Exporting Using the Clipboard the PostScript commands and the ChemDraw ChemDraw includes several formats on the Laser Prep are transferred with each drawing. The transferred drawings can be printed ChemDraw supports the following formats: independently of ChemDraw. Some file formats do not support atom labels that contain nicknames or structural fragments. This is a public variable attachment points, and multicenter bonds tagged file format that stores information about a are not be saved. However, all ChemDraw ChemDraw Stationery/Style specific information is preserved. Preview in various illustration, desktop publishing, and desktop presentation applications. Encapsulated PostScript (Text) Windows Postscript with Preview files contain the (Macintosh) scalable PostScript representation and the Windows PostScript, *. If a reaction contains application running on the same operating multiple arrows, then the largest arrow is used as the reaction arrow. However, in some cases, such as window with a spectrum of a standard size that can different arrow types, the arrow is converted to the be re-sized by dragging.

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Ever since her rejection of him at the age of eighteen medicine in french purchase 480 mg septra amex, she had been convinced that she had left behind a seed of hatred in him that could only grow larger with time treatment guidelines order 480mg septra overnight delivery. She had always counted on that hatred symptoms e coli cheap septra 480mg on-line, she had felt it in the air when the phantom was near treatment management company buy generic septra canada, and the mere sight of him had upset and frightened her so that she never found a natural way to behave with him medicine dictionary prescription drugs cheap septra 480 mg visa. On the night when he reiterated his love for her medications 319 buy cheap septra on line, while the flowers for her dead husband were still perfuming the house, she could not believe that his insolence was not the first step in God knows what sinister plan for revenge. When she awoke thinking about him on the day after the funeral, she succeeded in removing him from her thoughts by a simple act of will. But the rage always returned, and she realized very soon that the desire to forget him was the strongest inducement for remembering him. Then, overcome by nostalgia, she dared to recall for the first time the illusory days of that unreal love. She tried to remember just how the little park was then, and the shabby almond trees, and the bench where he had loved her, because none of it still existed as it had been then. They had changed everything, they had removed the trees with their carpet of yellow leaves and replaced the statue of the decapitated hero with that of another, who wore his dress uniform but had no name or dates or reasons to justify him, and who stood on an ostentatious pedestal in which they had installed the electrical controls for the district. Her house, sold many years before, had fallen into total ruin at the hands of the Provincial Government. It was not easy for her to imagine Florentino Ariza as he had been then, much less to believe that the taciturn boy, so vulnerable in the rain, was the moth-eaten old wreck who had stood in front of her with no consideration for her situation, or the slightest respect for her grief, and had seared her soul with a flaming insult that still made it difficult for her to breathe. Cousin Hildebranda Sanchez had come to visit a short while after Fermina Daza returned from the ranch in Flores de Maria, where she had gone to recuperate from the misfortune of Miss Lynch. Old, fat, and contented, she had arrived in the company of her oldest son who, like his father, had been a colonel in the army but had been repudiated by him because of his contemptible behavior during the massacre of the banana workers in San Juan de la Cienaga. The two cousins saw each other often and spent endless hours feeling nostalgia for the time when they first met. On her last visit, Hildebranda was more nostalgic than ever, and very affected by the burden of old age. In order to add even greater poignancy to their memories, she had brought her copy of the portrait of them dressed as old-fashioned ladies, taken by the Belgian photographer on the afternoon that a young Juvenal Urbino had delivered the coup de grace to a willful Fermina Daza. For Hildebranda it was impossible not to speak of Florentino Ariza, because she always identified his fate with her own. She evoked him as she evoked the day she had sent her first telegram, and she could never erase from her heart the memory of the sad little bird condemned to oblivion. For her part, Fermina had often seen him without speaking to him, of course, and she could not imagine that he had been her first love. She always heard news about him, as sooner or later she heard news about anyone of any significance in the city. It was said that he had not married because of his unusual habits, but she paid no attention to this, in part because she never paid attention to rumors, and in part because such things were said in any event about men who were above suspicion. On the other hand, it seemed strange to her that Florentino Ariza would persist in his mystic attire and his rare lotions, and that he would continue to be so enigmatic after making his way in life in so spectacular and honorable a manner. Nevertheless, on the night she met him in the movie theater just after her return from Flores de Maria, something strange occurred in her heart. What did surprise her was that he was so well preserved, that he behaved with the greatest self-assurance, and it did not occur to her that perhaps it was she, not he, who had changed after the troubling explosion of Miss Lynch in her private life. From then on, and for more than twenty years, she saw him with more compassionate eyes. On the night of the vigil for her husband, it not only seemed reasonable for him to be there, but she even understood it as the natural end of rancor: an act of forgiving and forgetting. That was why she was so taken aback by his dramatic reiteration of a love that for her had never existed, at an age when Florentino Ariza and she could expect nothing more from life. The mortal rage of the first shock remained intact after the symbolic cremation of her husband, and it grew and spread as she felt herself less capable of controlling it. Even worse: the spaces in her mind where she managed to appease her memories of the dead man were slowly but inexorably being taken over by the field of poppies where she had buried her memories of Florentino Ariza. And so she thought about him without wanting to , and the more she thought about him the angrier she became, and the angrier she became the more she thought about him, until it was something so unbearable that her mind could no longer contain it. The night he reiterated his love to Fermina Daza he had wandered aimlessly through streets that had been devastated by the afternoon flood, asking himself in terror what he was going to do with the skin of the tiger he had just killed after having resisted its attacks for more than half a century. In the sudden silence of other voices, Florentino Ariza recognized the voice of the man whom Leona Cassiani and he had heard singing many years before, at the same hour and on the same corner: I came back from the bridge bathed in tears. A song that in some way, on that night, for him alone, had something to do with death. He needed Transito Ariza then as he never had before, he needed her wise words, her head of a mock queen adorned with paper flowers. He could not avoid it: whenever he found himself on the edge of catastrophe, he needed the help of a woman. It would not be the first time he had knocked at her door in the wasteland of his sleepless nights, but he knew that she was too intelligent, and that they loved each other too much, for him to come crying to her lap and not tell her the reason. After a good deal of thought as he sleepwalked through the deserted city, it occurred to him that he could do no better than Prudencia Pitre, the Widow of Two, who was younger than he. They had first met in the last century, and if they stopped meeting it was because she refused to allow anyone to see her as she was, half blind and verging on decrepitude. As soon as he thought of her, Florentino Ariza returned to the Street of the Windows, put two bottles of port and a jar of pickles in a shopping bag, and went to visit her, not even knowing if she was still in her old house, if she was alone, or if she was alive. Prudencia Pitre had not forgotten his scratching signal at the door, the one he had used to identify himself when they thought they were still young although they no longer were, and she opened the door without any questions. He was surprised at how much she had aged since the last time he saw her, and he was aware that she saw him the same way. But he consoled himself by thinking that in a moment, when they had both recovered from the initial shock, they would notice fewer and fewer of the blows that life had dealt the other, and they would again seem as young as they had been when they first met. She had been awakened from her siesta by the thundering artillery that made the earth tremble, by the dissonances of the marching bands, the confusion of funeral hymns over the clamoring bells in all the churches, which had been ringing without pause since the previous day. From her balcony she had seen the cavalry in dress uniform, the religious communities, the schools, the long black limousines of an invisible officialdom, the carriage drawn by horses in feathered headdresses and gold trappings, the flag-draped yellow coffin on the gun carriage of a historic cannon, and at the very end a line of old open Victorias that kept themselves alive in order to carry funeral wreaths. They drank port and ate pickles on slices of country bread that Prudencia Pitre cut from a loaf in the kitchen. They had spent many nights like this after she had been left a widow without children. Florentino Ariza had met her at a time when she would have received any man who wanted to be with her, even if he were hired by the hour, and they had established a relationship that was more serious and longerlived than would have seemed possible. Although she never even hinted at it, she would have sold her soul to the devil to marry him. She knew that it would not be easy to sub mit to his miserliness, or the foolishness of his premature appearance of age, or his maniacal sense of order, or his eagerness to ask for everything and give nothing at all in return, but despite all this, no man was better company because no other man in the world was so in need of love. But no other man was as elusive either, so that their love never went beyond the point it always reached for him: the point where it would not interfere with his determination to remain free for Fermina Daza. They talked, not concerned about the hour, because both were accustomed to sharing the sleepless nights of their youth, and they had much less to lose in the sleeplessness of old age. Although he almost never had more than two glasses of wine, Florentino Ariza still had not caught his breath after the third. He was dripping with perspiration, and the Widow of Two told him to take off his jacket, his vest, his trousers, to take off everything if he liked, what the hell: after all, they knew each other better naked than dressed. He said he would if she did the same, but she refused: some time ago she had looked at herself in the wardrobe mirror and suddenly realized that she would no longer have the courage to allow anyone-not him, not anyone-to see her undressed. Florentino Ariza, in a state of agitation that he could not calm with four glasses of port, talked at length about the same subject: the past, the good memories from the past, for he was desperate to find the hidden road in the past that would bring him relief. When he saw the first light of dawn on the horizon, he attempted an indirect approach. And she began to sing, in a very good voice, the song that was popular then: Ramona, I cannot live without you. The night was over, for he did not dare to play forbidden games with a woman who had proven too many times that she knew the dark side of the moon. But now it was he, not they, who crossed the street, so they would not see the tears he could no longer hold back, not his midnight tears, as he thought, but other tears: the ones he had been swallowing for fifty-one years, nine months and four days. He had lost all track of time, and did not know where he was when he awoke facing a large, dazzling window. He had kept her bedroom intact, and he would sleep there to feel less alone on the few occasions when he was troubled by his solitude. He knew that it was Saturday, because that was the day the chauffeur picked up America Vicuna at her boarding school and brought her back to his house. He realized that he had slept without knowing it, dreaming that he could not sleep, in a dream that had been disturbed by the wrathful face of Fermina Daza. He bathed, wondering what his next step should be, he dressed very slowly in his best clothing, he dabbed on cologne and waxed the ends of his white mustache, he left the bedroom, and from the secondfloor hallway he saw the beautiful child in her uniform catching the ball with the grace that had made him tremble on so many Saturdays but this morning did not disquiet him in the least. America Vicuna ordered an enormous glass filled with layers of ice cream, each a different color, her favorite dish and the one that was the most popular because it gave off an aura of magic. Florentino Ariza drank black coffee and looked at the girl without speaking, while she ate the ice cream with a spoon that had a very long handle so that one could reach the bottom of the glass. On Sunday he sent the automobile for her in the event she wanted to take a drive with her friends, but he did not want to see her, because since the previous week he had come to full consciousness of both their ages. That night he decided to write a letter of apology to Fermina Daza, its only purpose to show that he had not given up, but he put it off until the next day. On Monday, after exactly three weeks of agony, he walked into his house, soaked by the rain, and found her letter. He knew that his Spartan, bland supper was on the table in the dining room, but the slight hunger he felt after so many days of haphazard eating vanished with the emotional upheaval of the letter. His hands were shaking so much that it was difficult for him to turn on the overhead light in the bedroom. He put the rain-soaked letter on the bed, lit the lamp on the night table, and with the feigned tranquillity that was his customary way of calming himself, he took off his wet jacket and hung it on the back of the chair, he took off his vest, folded it with care, and placed it on top of the jacket, he took off his black silk string tie and the celluloid collar that was no longer fashionable in the world, he unbuttoned his shirt down to his waist and loosened his belt so that he could breathe with greater ease, and at last he took off his hat and put it by the window to dry. Then he began to tremble because he did not know where the letter was, and his nervous excitement was so great that he was sur prised when he found it, for he did not remember placing it on the bed. Before opening it, he dried the envelope with his handkerchief, taking care not to smear the ink in which his name was written, and as he did so it occurred to him that the secret was no longer shared by two people but by three, at least, for whoever had delivered it must have noticed that only three weeks after the death of her husband, the Widow Urbino was writing to someone who did not belong to her world, and with so much urgency that she did not use the regular mails and so much secretiveness that she had ordered that it not be handed to anyone but slipped under the door instead, as if it were an anonymous letter. He did not have to tear open the envelope, for the water had dissolved the glue, but the letter was dry: three closely written pages with no salutation, and signed with the initials of her married name. He sat on the bed and read it through once as quickly as he could, more intrigued by the tone than by the content, and before he reached the second page he knew that it was in fact the insulting letter he had expected to receive. He laid it, unfolded, in the light shed by the bed-lamp, he took off his shoes and his wet socks, he turned out the overhead light, using the switch next to the door, and at last he put on his chamois mustache cover and lay down without removing his trousers and shirt, his head supported by two large pillows that he used as a backrest for reading. At last he placed it, without the envelope, in the drawer of the night table, lay on his back with his hands behind his head, and for four hours he did not blink, he hardly breathed, he was more dead than a dead man, as he stared into the space in the mirror where she had been.

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Funeral the risk of water contamination varies according to the type of access to drinking-water medications xerostomia order generic septra pills. A-3 Arrangements should be made for the protection of water A-4 sources as an important measure for reducing the risk of contamination medicine 911 cheap septra master card. There is evidence that storage in a narrow-mouthed vessel with a protected dispenser (spigot symptoms 14 dpo cheap septra online american express, spout) is much safer than storage in a wide-mouthed vessel medications that cause pancreatitis order generic septra online. It is better to pour the water from the container than to use a potentially contaminated article medicine 773 order septra cheap online. Is there any regulation to ensure minimum levels of hygiene A-4 for food products in the marketplace Are any local dishes made with raw seafood (particularly A-6 crustaceans and other shellfish) or raw fruit or vegetables (see tip 10 medicine reaction buy septra no prescription. Are food handlers who sell raw or partially processed animal products for immediate consumption required to display a sign that informs the public of the increased health risk associated with consuming such food Mortality from contaminated water and eaten raw or insufficiently cooked or contaminated during preparation. What percentage of the population was served with improved sanitation facilities (see tip 11. Was there a good system in place for excreta management and disposal during the outbreak (latrine emptying and sludge removal from septic tanks) Could the sanitation facilities potentially contaminate any drinkingwater sources Was consideration given to providing sanitation services for highrisk communities during the outbreak (see tip 11. Were health workers properly trained to teach local people about good hygiene behaviours (see tip 11. Confirmation A good inventory of existing sanitation facilities (improved and not improved) should be compiled to evaluate the disease 3. Partners the population should have access to an improved sanitation facility, such as connection to a public sewer, connection A-1 to a septic tank, pour-flush latrine, simple pit latrine, and A-2 ventilated improved latrine. A-3 Facilities such as bucket latrines, public or shared latrines, and A-4 trenches should be replaced as soon as possible by improved A-5 sanitation facilities. Without their participation and involvement there is a risk of misuse or non-use of the sanitation facilities. Sanitation facilities should be hygienic so that they do not endanger the health of the users and the community as a whole. Were there any official recommendations with regard to funeral practices, such as funeral gatherings, ritual washing 9. Were communities aware of what to do with cholera patients A-1 who died at home (see tip 12. Were health care workers, especially in cholera camps, well A-3 trained in handling corpses (see tip 12. If funeral feasts cannot be cancelled, meticulous handwashing with soap and clean water is essential before food is prepared and handled. A designated health worker present at the funeral gathering can be helpful in supervising the use of hygienic practices. For transporting corpses of cholera patients, corpse-carriers should wear gloves; corpses should be carefully wrapped. Were data from previous outbreaks available and used to provide better understanding of the current outbreak Was there a good analysis of data by time, area, and high-risk group during the outbreak Was the information collected and analysed promptly enough to be used in monitoring the outbreak (see tips 13. What kind of difficulties arose during the investigation (logistics, contact with media, delay in organizing the 9. Regular analysis of baseline data (person, place, time) is therefore valuable for adequate preparedness and for efficient monitoring of the cholera situation. Although a formal epidemiological investigation is not essential for cholera as the major routes of transmission and measures to be taken are well known, it may be valuable to identify high-risk activities or vehicles of transmission. Was there any formal mechanism for raising funds to support A-1 the outbreak response Which organization was coordinating the various partners A-3 involved in the outbreak response (see tip 14. Was there any strategic plan for the response, with specific A-5 tasks assigned to each partner (see tip 14. It might therefore be useful to make an inventory of A-5 support provided (see Appendix 9). A-6 According to international partners, the support provided may A-7 be technical support alone or both financial and technical A-8 support. Partners Javelle water 1 [is itself a 1% stock solution] A-1 A 1% solution contains 10 g of chlorine per litre = 10 000 mg/litre or A-2 10 000 ppm (parts per million). A-3 1 tablespoon = 3 teaspoons A-4 Avoid skin contact with any of the chemical sources or the stock A-5 solution, and avoid inhaling chlorine fumes. Wait for 30 minutes, then use a comparator or test strip to measure the residual free chlorine concentration. Calculate the amount of 1% chlorine solution needed for the quantity of water to be treated. Hygiene When there is a delay between cooking and eating food, as when food is sold in restaurants or by street vendors, it should 8. Foods for infants should be eaten immediately after A-1 being prepared, and should not be stored at all. After preparing raw foods, such as fish or shellfish, wash your hands again before handling other foods. Cloths used for washing or drying food, preparation surfaces, dishes, and utensils should be changed every day and boiled before reuse. A-3 Guidelines for the collection of clinical specimens during field investigation of outbreaks. Cholera endemic area, cholera hotspot, cholera outbreak, cholera alert and cholera elimination 5 2. Cholera transmission is closely linked to inadequate access to clean water and sanitation. Typical at-risk areas include peri-urban slums and rural areas where basic infrastructure is not available, as well as camps for internally displaced persons or refugees, where living conditions and access to water and sanitation systems are disrupted. However, the true number of cholera cases occurring globally is thought to be much higher. Factors contributing to underreporting of cases and deaths may include weak surveillance systems, inconsistencies in case definitions, lack of laboratory diagnostic capacities, fear of negative impact on travel and trade, etc. An operational surveillance system for cholera is crucial for detecting outbreaks, monitoring disease occurrence and estimating disease burden to orient implementation of prevention and control measures and to allocate resources. The objective of this guidance document is to support the public health professionals in implementing effective surveillance of cholera in at-risk, endemic and epidemic areas. Areas with poor sanitation, limited access to safe water and deficient hygiene practices are considered at high risk for cholera transmission. In addition, limited access to health care facilities and inadequate treatment of cases are factors associated with high cholera-related mortality. Long term multi-sectoral prevention and control strategies ensuring adequate access to water and sanitation, social mobilization for health and hygiene promotion, immunization, surveillance, and rapid appropriate case management are essential for reducing the morbidity and mortality of cholera in endemic and epidemic contexts. An effective surveillance system aims to provide reliable and timely data to detect outbreaks in both endemic and non-endemic areas, monitor morbidity and mortality trends, and identify hotspots in areas where cholera disease is endemic, in order to implement adequate control measures to minimise the impact of the disease in the population. In addition, well-performing laboratories contribute to surveillance through timely and accurate testing of samples to confirm or discard Vibrio cholerae as the causative agent, to monitor the outbreak, and to characterise and determine antibiotic susceptibility of the circulating V cholerae strains. For cholera, key factors for effective surveillance include existence of a standard case definition, simple data collection tools, clear reporting procedures, analysis plans, rapid diagnosis of suspected cases and laboratory confirmation, routine feedback of surveillance data, and appropriate coordination at all levels of the public health sector. In this line, activities for strengthening and improving the surveillance of cholera in a specific area or country should focus on providing to health professionals clear guidance on standard case definitions, data collection and reporting procedures, ensuring laboratory capacity to detect and confirm cholera, and involving all key actors and community for early detection and response effectively to outbreaks. Suspected cholera case In areas where a cholera outbreak has not been declared: Any patient aged 2 years and older presenting with acute watery diarrhoea and severe dehydration or dying from acute watery diarrhoea. In areas where a cholera outbreak is declared: any person presenting with or dying from acute watery diarrhoea. An area can be defined as any subnational administrative unit including state, district or smaller localities. Note: Any country that contains one or more subnational administrative units that are endemic, as defined above, is considered a cholera-endemic country. Outbreaks can also occur in areas with sustained (year-round) transmission, and are defined as an unexpected increase (in magnitude or timing) of suspected cases over two consecutive weeks of which some are laboratory confirmed. Such increases should be investigated and responded to appropriately through additional outbreak response and control measures. Cholera elimination Any country that reports no confirmed cases with evidence of local transmission for at least 3 consecutive years and has a well-functioning epidemiologic and laboratory surveillance system able to detect and confirm cases. Surveillance of cholera disease An effective surveillance system is crucial for detecting outbreaks and for monitoring trends of disease over time. The surveillance system should aim to collect reliable and timely data to identify vulnerable populations and high risk areas to guide preventive and control measures including improving access to safe water and sanitation, health and hygiene education in the community, immunization of at-risk population, and adequate and timely access to patient care. However, detection and reporting of cholera cases is usually hampered by inadequate access to healthcare, deficient training in surveillance (lack of clear case definitions, data collection and reporting procedures), and limited availability of laboratories for confirmation. Any cholera alert, as defined above, reported through routine surveillance, community-based surveillance, or through unstructured information or rumours should trigger a field investigation to confirm or rule out the outbreak. Stool samples from suspected patients should be collected for laboratory confirmation which will then serve as the basis for outbreak declaration. Once the outbreak is declared the surveillance systems should provide timely information to monitor trends, identify populations at risk and guide the implementation of control and treatment measures. The number of cases and the number of deaths should be systematically reported and reviewed at the level of the surveillance system (including district and health facility levels) to monitor trends and to detect outbreaks. In endemic areas, historical data is essential to estimate the expected number of cases and establish thresholds to support the detection of outbreaks. The expected number of cases is determined by analysing past acute watery diarrhoea cases (or cholera cases where lab surveillance is adequate) in the affected area (province, region, district, community, etc) during similar time periods. Any unexpected excess of suspected and confirmed cases should be followed by an investigation to confirm or rule out cholera. Once a cholera outbreak is suspected, the following steps should be undertaken immediately and simultaneously: 1. Rapid implementation of standard diarrhea prevention and control measures to reduce further spread of the disease and reduce the mortality. Implementation of Early Warning and Response with a focus on Event-Based Surveillance. Community health workers should capture and immediately report any cholera alert to the health facility/district health department who shall initiate a field investigation to verify the information, confirm the cholera outbreak and implement control measures. Environmental surveillance Cholera disease is primary a water-borne disease where sewage-contaminated water sources, such as municipal water supplies, rivers, streams, or wells, are the principal route of disease transmission. In an epidemic setting, water and food are usually contaminated by Vibrio cholerae strains from human faeces, however Vibrio cholerae can survive in aquatic environments for extended periods, especially in estuarine and saline waters. Various biological and physicochemical factors, such as nutrient content, salinity, temperature, and pH, may influence the growth, survival, and distribution of Vibrio cholerae in aquatic environments. Monitoring the presence of Vibrio cholerae in specific environmental water sources may help with early detection of cholera transmission in some areas and to identify the sources or vehicles for infection. Isolation of Vibrio cholerae in water sources All water specimens should be collected in sterile containers and transported to the laboratory for isolation.

References

Kavoussi LR, Peters CA: Laparoscopic pyeloplasty, J Urol 150:1891, 1993.
Tasali E, Leproult R, Ehrmann DA, et al: Slow-wave sleep and the risk of type 2 diabetes in humans, Proc Natl Acad Sci USA 105:1044n1049, 2008.
Attitudes of critical care medicine professionals concerning forgoing life-sustaining treatments. The Society of Critical Care Medicine Ethics Committee. Crit Care Med. 1992;20(3): 320-326.
Heesakkers, R.A., Hovels, A.M., Jager, G.J. et al. MRI with a lymph-node-specific contrast agent as an alternative to CT scan and lymph-node dissection in patients with prostate cancer: a prospective multicohort study. Lancet Oncol 2008;9:850-856.
Vest MT, Tanoue L, Soulos PR, et al. Thoroughness of mediastinal staging in stage IIIA non-small cell lung cancer. J Thorac Oncol 2012;7(1):188-195.