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By: Jennifer Lynn Garst, MD

  • Professor of Medicine
  • Member of the Duke Cancer Institute

https://medicine.duke.edu/faculty/jennifer-lynn-garst-md

It is observed that chronic alcoholics suffer from thiamin deficiency arthritis in the fingers exercises diclofenac 50mg line, as the need for thiamin increases with ingestion of alcohol arthritis wiki generic diclofenac 50 mg without prescription. For example arthritis medication uk generic 100 mg diclofenac free shipping, thiamin and niacin are partially lost in refining and polishing of cereals rheumatoid arthritis scholarship discount diclofenac 100mg fast delivery, such as rice and wheat. Parboiling helps to conserve these vitamins and in regions of the country like Kerala, where parboiled rice is consumed, incidence of thiamin deficiency, is rare. However, marginal deficiency could still exist in homes in rice eating areas, if practices such as excessive washing of rice before preparation and discarding the water in which rice is cooked are still prevalent. Beri-beri, a disease caused by thiamin deficiency, used to be endemic in the coastal parts of Andhra, especially where the rice polished in mills was used. The enactment of laws making under-milling compulsory and improvement in the technology of milling may be one of the reasons for reduction of this deficiency. Another reason possibly is the change in dietary habits of the people, such as inclusion of foods such as wheat and wheat products, which contain thiamin, in the diet. Beri-beri, which is caused by deficiency of thiamin, can affect children as well as adults. The most serious victim is the baby of a mother, who does not secrete enough milk and has little thiamin in her milk. In such thiamin deficient infants, one of the symptoms is the visible cry in which the child appears to be crying, without making any noise. The disease occurs between the first and fifth month and it strikes suddenly and could result in death, if no adult is looking after the child, when the mother is away at work. Little siblings, who may be in-charge, may not realise that the infant is crying and is in need of nourishment. In adults, thiamin deficiency could result either in dry beri-beri or wet beri-beri. Dry beri-beri is characterised by arms and legs wasting away, losing their sensation. Wet beri-beri is accompanied by swelling of the limbs and impaired function of the heart; it could ultimately result in death due to cardiac failure. Riboflavin deficiency is frequently observed in children and some adults among the low income groups in India. The symptoms of this deficiency are cracks in the skin and corners of the mouth, known as cheilosis. The deficiency of niacin occurs, when the staple cereals are highly refined and intake of dals and legumes is meagre. Niacin deficiency is called pellagra (rough skin) and it affects the skin, the gastro intestinal tract and the nervous system. There are rashes on the skin (dermatitis), which at times can affect the whole body (Figure 13. The effect on the nervous system results in lack of alertness, anxiety and irritability. This could slowly develop into a situation in which the person affected may become mentally confused and could even Disorders of Nutrition 153153153153153 lead to insanity. Sporadic incidence of pellagra, a disease occurring due to severe deficiency of niacin, is reported from regions, where jowar (sorghum vulgare) is the staple. Jowar is not low in niacin and tryptophan, the amino acid from which it can be synthesised in the body. The studies carried out at the National Institute of Nutrition, Hyderabad, seem to indicate that amino acid imbalance (high leucine/low iso leucine) may be the cause of pellagra prevalent in the regions, where jowar is the staple food. This is more so during lean periods when jowar may be the only source of nourishment and other foods to supplement the staple are not available. New strains of jowar with lower concentrations of leucine have been developed to prevent the sporadic occurrence of pellagra. Inclusion of other foods rich in thiamin such as wheat and wheat products, could help remove thiamin deficiency. Use of milk and milk products and other foods, which are rich sources of riboflavin, could prevent riboflavin deficiency. Use of a combination of cereals, pulses and inclusion of groundnuts, would help prevent B-complex deficiency. From the socio-economic point of view, endemic neuropsychic retardation may be the most important of the iodine deficiency disorders. One is often struck by the number of superficially normal-looking persons in the endemic regions, who on closer observation are found to be mentally subnormal or have mild defects in their motor function or have both these lacks simultaneously. It has been observed that large numbers of cases of mild or moderate retardation in intellectual, motivational or neuromotor maturation occur in conjunction with endemic goitre. In order to focus attention on this multifaceted nature of iodine deficiency, these disorders are now referred to as iodine deficiency disorders and not goitre. Apart from the sub-Himalayan states, which were always known to be goitre-prone, recent surveys have shown the presence of endemic pockets in Andhra Pradesh, Madhya Pradesh, Maharastra, Bihar, Gujarat end Kerala as well. The ultimate sequel is occurrence of cretinism in children born to women, who were so severely depleted that they could not provide iodine for proper development of the foetus. Cretins have low basal metabolism, and suffer from muscular weakness, dry skin, mental retardation and their skeletal development is arrested. If desiccated thyroid is given to such infant, early enough, there is noticeable improvement in physical development, mental retardation may be less severe, but any damage, which may have taken place in the central nervous system, cannot be reversed. The simplest way of eradicating iodine deficiency is by addition of iodine to the diet. This procedure is inexpensive and within the technological capability of our country. However, there have been some difficulties in the distribution of iodised salt and the progress in eradication of this deficiency has been slow. In view of the high incidence of the deficiency and its deleterious effects on the health of future generation, there has been a new momentum in the implementation of iodine prophylactic programmes in the developing world. In India, the government has decided to extend the salt iodation programme to cover the entire country by 1993 in a phased manner. In view of the high incidence of anaemia in the country, now attempts are being made to fortify salt with both iron and iodine. The doubly fortified salt is going to be field tested in Uttar Pradesh and A ndhra Pradesh. It will be our duty to educate the public about the importance of using the fortified salt. Write short notes on: (a) Vitamin A deficiency (b) Iron deficiency anaemia (c) Causes of anaemia (d) Vitamin B-complex deficiency (e) Iodine deficiency disorders 156156156156156 Fundamentals of Foods, Nutrition and Diet Therapy (f) Cretinism (g) Fortification of foods. Practical Work (a) Plan and prepare nutritionally adequate meals for under-nourished toddlers and pre-school children by use of multi-mixes (at least five simple preparations) steamed, soft-cooked and boiled foods. You need a plan to select an adequate diet so simple and attractive that everyone including you, a young student as also the elderly family members can understand and follow it. This practical plan, known as a food guide, helps to ensure good nutrition through proper food selection. As you know, food availability and meal patterns vary from one country to another. In developing a food guide, the foods are classified on the basis of their use and the major nutrients which they provide. Most preparations use oils and fats as a seasoning, and jaggery or sugar as a sweetener. Cereals and their products – Energy, protein, iron, thiamin, niacin, Rice, wheat, jowar, bajra, ragi, maize, fibre other millets and their products 2. Protein foods – Proteins, energy, calcium, iron, B Dals, legumes, milk, eggs, fish, poultry, complex vitamins, invisible fat, fibre meat and their products 3. Protective vegetables and fruits – Carotenoids, vitamin C, iron, (a) All green leafy vegetables, orange calcium, folic acid, fibre yellow fruits and vegetables (b) Vit. Other vegetables and fruits – Supplementary sources of minerals, All gourds, beans, peas, potatoes, vitamins and fibre onions, etc. Food Guides for Selecting an Adequate Diet 161161161161161 Food Guide for Selecting an Adequate Diet All the foods we use in our daily meals are divided into five groups in the food guide for India. The food groups are chosen because of the specific nutrients contributed by each to the total diet.

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Often we eliminate large quantities of wastes in the form of mucus as we develop colds or flu arthritis diet nightshade purchase diclofenac 100 mg free shipping. Even when in good condition chronic arthritis in the knee diclofenac 50 mg mastercard, it is important to different types arthritis in dogs purchase 50 mg diclofenac otc bathe once or twice daily to best treatment for arthritis in feet order diclofenac 100mg online remove these wastes from the surface of the skin, thus allowing it to breathe properly. The Simple Art of Nutrition There are simple, well-defined laws or rules to follow to obtain the utmost from the preparation and use of foods. Only when we follow these laws and live within their simplicity does our blood become pure and our minds serene. As we live within these simple laws we can dismiss all thoughts of disease, and it will never be necessary to seek help or relief from any outside source. This excellent health has been achieved in thousands of cases involv ing every variety of disease condition. All diseases and adverse condi tions respond and disappear as we discover the healthy way. Cleansing, building, and retaining is the master plan of this simple form of nutrition. Before building and retaining can be realized, cleans ing of the various toxins, poisons, and congestions must be complete. I offer you the finest in the cleansing and healing field in the form of the lemonade diet. In an article in the National Enquirer, July 22, 1975, there was the following prediction by Jeanne Dixon: "One of the greatest medical breakthroughs of the decade will come from the common citrus fruit. Scientists will create fantastic new wonder drugs from these fruits for a wide array of illnesses that have plagued mankind for centuries. It will 32 be learned that a chemical in the fruit can strengthen our natural resist ance to many diseases. These fantastic new wonder chemicals have already been discovered many years ago by me, and they are already being used in the form of the lemonade diet with tremendous success around the world. There is no need to further create these chemicals as God has already done a better job of it than any group of men can ever hope to do, regardless of their education or abilities. These chemicals are already in the citrus fruit to function at the highest level of efficiency because other necessary chemicals are present with them. As various chemicals are separated or isolated, unbalances, resulting in harmful side effects can occur, defeating the original plan to cleanse and build. Only when we use the best of foods in their original form, are we going to get the most out of them. For many years I have been telling my students that we always need the whole product instead of the various separated units such as carrot juice, vegetable juices, etc. There are many needed properties in the fibre also to assist in properly handling the juices. We know from excellent results that carrot juice, celery juice and other vegetable juices are excellent but how much better can they be if left intact and taken as is. Can we possibly get as much good and complete nutrition from drinking a dozen carrots without the fibre as we can from properly chewing the whole carrot and eating fewer carrots. Formerly we were told not to use fibre as it might cause a variety of colon troubles. In determining this importance and putting it to use should we go over board with the idea by using such things as wood fiber in bread, (good for termites but not much good for us) or say cereal, or perhaps some other foreign matter in these products or should we use it as it is originally without separating it in the first place. Reminds me of the white bread controversy — tests showed that white bread could not sustain life even though milk and eggs had been added so a variety of vitamins were added — enriched — fortified flour they called it. Then new standards were found or believed to be necessary so more enrich ments were added then extra iron — extra spoilage retardants or 33 preservatives appeared necessary — next extra fiber was found that important. Now after all these things were added just how good was the bread — taking things out and adding other things to replace them. The whole matter could have been prevented by leaving things as they were originally. Now if we can accept the whole procedure as a much needed lesson we can then leave the rest of our food as it is and stop taking extra wheat germ, lecithin, vitamins, minerals, fibre (bran or wood) and many other extras to supplement and enrich a large variety of separated and devitalized products. Another thought by so many people "If a small amount is good: then logic tells them that a lot can do so much more". Something is left out so whatdeficiencies have we created and what about the following side effects. It seems to me we should start all over again from the beginning: start eating things as they are in limited amounts to allow the body to digest and assimilate just the amount it can handle with no excesses. The use of a high protein for weight reducing became a fad and then a predigested protein is creating many serious deficiencies and developed a monster to the point that it was reported that many have died from lack of potassium, and other needed life qualities. This simple idea can and will save us a lot of time, money and useless research to test for possible deficiencies. The ideal purpose of any complete diet is to have all the vitamins, minerals, and nutrients in a readily available form in order to enable the body to function normally and to be free from diseases and other mal functions. Since many people of the world are already handicapped by a multi plicity of diseases, they must first cleanse the body before the right diet can be properly used. Therefore, what is eaten during these respective periods must be harmonious with the natural processes. Soup (homemade, veg etarian, of course) or tomato juice, hot or cold, may be taken with vegetable salad. Note: Recipes for coconut and almond milk, and for a number of dressings, are to be found on the following pages. On other occasions try special dishes such as vegetable stew, various types of brown rice dishes (curried rice, Spanish rice, chop suey and rice), chili beans (made with lima beans or red beans), or any recipe using lentils or garbanzos — but no meat, of course. Vegetarian cutlets, and all similar commercially-produced meat substitute preparations, should be used very, very sparingly, or not at all. An occasional mono diet meal is always beneficial such as brown rice with coconut milk and a little maple syrup only, steamed artichokes only, fresh green corn only, watermelon, strawberries, honeydew. It is very time consuming, costly and does not accomplish the desired results that simplification can. Different types of foods have different requirement in time and abilities to properly digest them. The coconut milk produced in this fashion makes a tasty, nutritious beverage for children or adults in place of animal milk. A number of delicious drinks can be made by using coconut milk and your favorite fresh fruit liquefied together. Stop the blender and push them to the center with a knife several times as they stick to the sides. As liquefier is running add sesame or safflower oil until the oil covers the pulp (approx. Liquefy for 2 minutes and then add warm water until mixture reaches the desired thickness (approx. Push them to the center with a knife several times as they stick to the side as the blender is running. A couple of dill pickles and sweet relish may be added to provide the Thousand Island taste. Add the potato flour as needed if you desire the dressing to be thicker and creamier. Other herbs and spices may be used very delicately instead of the suggested ones to create a variety of dressings. Slowly add potato flour as liquefier is running until desired thickness is achieved. Continue stirring as you add hot water until you have the desired thick ness (approx. These forms of blemishes are not caused by a virus, but are a form of fungus growth feeding on acid elimination in the skin. Use for all insect stings and bites (wasp and mosquito, for example), scratches, small burns, and sores that are slow in healing. Use your finger to put a small amount on the back of the tongue for sore throat or a tickling cough. For those who wish to quite smoking — every time you have the desire for a smoke place — with your finger — a small amount on back of the tongue and you immediately lose your desire to smoke.

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Of course arthritis in dogs glucosamine dosage diclofenac 50 mg for sale, this speaks nothing of the similar effects that Daubert hearings would have on the criminal docket rheumatoid arthritis in feet symptoms discount diclofenac 50mg free shipping, which is every bit as zyflamend arthritis pain generic 50mg diclofenac free shipping, if not more so rheumatoid arthritis definition ppt buy 50 mg diclofenac, burdened than the civil docket. I view this proposed rule as one that sacrifices a great deal and accomplishes very little. Is it more important to have a three hour evidentiary hearing on the minutiae of an expert’s opinion, or to process thousands of cases in a timely, fair, and efficient manner? Is it more desirable to weed out the infinitesimal number of so called “junk” expert opinions, or to prevent unruly litigants and their counsel from abusing the pleading and discovery process to gain tactical delays? In my experience, the answer to these questions and h lik h i b i l f li i i hi k f i l 360 Florida has Frye as a measuring stick. The Frye measure has Florida law, which has interpreted it and the courts understand its appropriate application. Secondarily, it will serve as a feast for corporate defense lawyers and prosecutors to use to slice up justice until it is unrecognizable. Daubert should not be adopted for several more reasons: First: Daubert has proven to be a complete failure in the federal court system. Daubert is burdensome and a tool used by insurance and big business to create litigation, drive up costs, and exclude reliable, traditionally accepted scientific evidence. The 2013 statute passed by the legislature, which attempts to force Daubert onto our justice system, was a special interest handout to the insurance industry and criminal defense bar. By passing this law, the legislature tried to, by unconstitutional legislative fiat which infringes upon the constitutional authority solely reserved to the Supreme Court, force an abdication of Frye in favor of Daubert. Many more motions and lengthy hearings are placing an undue burden on our already overtaxed court system. It is not unusual for there to be multi-day hearings that are essentially “trials within trials” just on evidence. The Daubert standard requires judges to become amateur scientists in many different areas and forces them to evaluate individual studies; requiring them to look at potential error rates, etc. Since the judge is asked to individually evaluate the science, there will be multiple different rulings from different judges based upon the same science, resulting in confusion and inconsistency. The Daubert bill, but not the amendments themselves, also includes a whereas clause that expresses the intent to overrule the Florida Supreme Court’s decision in Marsh v. Imposing a Daubert rule will increase the costs of litigation and will further tax the time courts have to handle controversies. The Bar should adopt the majority report position and reject an attempt to adopt the Daubert standard as an evidentiary procedure rule. Under the Daubert standard, litigants are forced into unnecessary and very costly evidentiary trials within trials. This Frye standard ensures that scientific evidence is reliable without placing an impossible burden on judges. The attempted change is unnecessary and it will be detrimental to our system of justice in Florida. The Frye standard is a more objective standard that would help create consistency in qualifying experts for trial. In what can only be viewed as an attempt to overstep the judicial branches refusal to adopt Daubert, the Legislature (through money of special interests groups) has adopted Daubert. This standard requires judges to become scientists in different areas and forces them to evaluate individual "scientific" studies. The Daubert standard is too time-consuming, burdensome, and too costly for under-resourced Florida courts to apply. Trial judges are having to conduct "trials within trials" to apply the multi factorial and flexible Daubert standard thereby providing arbitrary results which cause confusion and inconsistency. The Florida Supreme Court views the Frye standard as the more objective test requiring scientific evidence to be generally accepted in the scientific community. The Frye standard has worked well in Florida for decades and has successfully screened junk science out of Florida courtrooms. The Frye standard ensures that scientific evidence is reliable while at the same time not overburdening our trial judges. Daubert will restrict access to justice and will exponentially increase case costs and delay trials more than they already are. This will further burden our already financially strapped judicial system, whose budget seems to decrease every year. Adding more procedural hoops to our already fragile judicial system will have catastrophic consequences, denying Floridians their right to a jury trial, and significantly increasing the time it takes to get to trial. We need to focus on the real problems of our judiciary, rather than manufacturing false problems. Daubert is being used as a sword to increase the cost and construct barriers to the consumers. Daubert operates as a lock on the courthouse doors to litigants who do not have the financial backing of the insurance industry or other moneyed interests. Daubert has been used as a tool for confusion and the confounding of basic evidentiary presentations, challenging even such basic notions as testimony by treating physicians on causation, diagnosis and prognosis. Daubert, in its original intent to make it easier to present expert testimony, has been perverted and turned on its head. It is seen by trial lawyers almost universally as a tool for exclusion of otherwise valid expert opinions. The need for complicated hearings which force round pegs into square holes is troubling. Importantly, this law is a procedural law, which is solely in the purview of the Supreme Court and outside the power of the Legislative branch. Frye, as recognized by the Florida Supreme Court, is more based in science and principle than Daubert, and Daubert is more likely to produce arbitrary results. Frye, unlike Daubert, requires the principles underlying expert testimony to be "generally accepted in the scientific community" therefore eliminating the subjectivity of experts, lawyers, or judges. Resolution of this issue at the earliest date by the Florida Supreme Court is needed. Despite not being adopted by the Florida Supreme Court, and thus not a rule of evidence, several courts have assumed that the Daubert standard is to be applied. The Daubert standard is time-consuming, burdensome, and costly for under-resourced Florida courts to apply and amounts to an unfunded mandate. Unfortunately, courts are under the impression that Daubert is the standard and is to be applied. As a result, additional motions are necessitated followed by extensive and costly hearings. The amount of time and money being wasted on Daubert is crushing our court system. Additionally, Daubert unfairly forces judges to become judges of science instead of law. Frye is the appropriate standard and has worked to allow valid case, and it provides sufficient protections against "junk science". The only reason to approve Daubert is to limit scientific evidence, and that will not only prevent valid prosecution of civil and criminal cases. Civil cases are important, but there is no question that requiring Daubert will result in allowing criminals to escape culpability for crimes they committed by improperly handcuffing the prosecution. Sacrificing the public safety to protect corporate interests is a horrible idea and thus Daubert should be rejected, and Frye should remain the law of the land. Daubert creates a burden on Plaintiff attorneys and the already burdened Judges to work Daubert hearings into almost ever civil litigation case. Everyone agrees the standard of Daubert is not changing admissibility but is slowing the court system. It is being used as a tool by corporations/defendants to delay litigation, and to significantly increase the expense a plaintiff already bears to pursue a cause of action. Based on my 40 years of trial experience, I can unequivocally say this is a bad evidentiary standard, and should not be implemented. While a majority of the legislature may have disagreed with the learned history steadfast decisions of the Court to reject the Daubert standard in the past, the fact that its members believe that their disagreement alone should change the way the Courts proceed is testament to the impropriety of the standard: it is motivated either by ignorance or overreach, both desiring nothing but to curtail the judicial process.

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Fevers caused by exposure to rheumatoid arthritis yeast infections discount diclofenac 50mg line heat are best treated by pouring cold (chilled with ice) water over the patient’s head arthritis in feet and knees order 50mg diclofenac mastercard, and by putting him in a cold bath arthritis turmeric quality diclofenac 100mg, while forceful massages and using much oil should be avoided arthritis medication and breastfeeding generic 100mg diclofenac. Adams also makes a note of how Alexander of Tralles criticized Galen for prescribing certain heating measures, such as hot foods and warm application to the stomach, and for not suggesting the dilution of the rubbing oil with water. For fevers characterised by faint and irregular pulse, very high body temperature, and poor digestion, it was advised to promote secretions from the body 589 (urine, sweat etc. However, in accordance to the general rule, if the fever was too high, the baths should be avoided, unless the signs of concoction were already visible, and the patient was of hot and dry constitution to begin with – in which case he might have been thrown into a cold bath. With only moderate fever and signs of concoction visible, the use of baths was allowed, as well as drinking of wine and 590 unctions “of a rarefying nature”. For tertian fevers (diseases with fevers recurring in 48-hour cycles, such as, for example, certain strains of malaria), characterized by agitated yellow bile and stiffening of the body in the early stages of the illness, the prescribed bathing was to take place in warm water, without the addition of salts, nitre or mustard. Two, or even more baths per day were allowed (providing that the signs of concoction appeared), if the patient was fond of them. Paul makes a note that this treatment was effective prior to his times, but that in modern days the daily regimen has changed, and the bile becomes mixed with phlegm, due to poor diet and little exercise, and the therapy needs to take this into account; bathing should therefore only be used after 591 concoction. The so-called spurious tertians were to be treated with tepid baths, but only after signs of concoction became visible. Galen noted that these spurious (or bastard) tertians were connected with diseases of the spleen, and recommended venesection 592 and warming of the body; this advice was repeated by the later authors. In cases of quartan fever (attributed to the excess of black bile), as well as quotidian, continual and hepialus (intermittent) fever, bathing is not specifically 593 mentioned. The semi-tertian fever, which are a mixture of tertians and quotidians, 589 Paul of Aegina, Epitome, 2, 17. In case of a synochous (continuous) fever, accompanied by effervescence of blood, Galen’s advice was to abstain from bathing, while Aetius allowed bathing on 595 the fourth day (presumably the time when the inflammation was expected to pass). In case of ardent fevers, characterized by blackened, dry tongue, watchfulness and pale excrements, the cure involved evacuating the bilious humours, and bathing was allowed only for the patients who did not suffer from inflammation or swelling caused by erysipelas (skin infection). Cooling the patient through washing with a sponge and pouring cold water on the patient, and cold drinks and applications was 596 generally recommended. For strictly erysipelatous fevers, bathing was strongly discouraged, although at the fever’s peak, the patient was supposed to be given very cold applications, and if 597 that was insufficient, internal cooling was to be used as well. The hectic (recurrent) fevers, as Paul describes them, are seated in the fluids, spirits and solid parts, and therefore the affected might not even recognize that they 598 have a fever, as all of the body parts are equally heated. Curing such fevers involved primarily a moistening diet, when inflammation was present. External cooling applications could be used in more extreme cases, and 599 bathing was an appropriate measure at all times. Adams remarks that Galen was an ardent supporter of cold baths used for treating hectic fevers, though the ancient physician also noted that inflammatory or erysipelatous symptoms of vital organs and an excess of crude and putrid humours in the body may compel patients to abstain from bathing. In all other cases of hectic fever, however, Galen saw bathing as the only real cure. In addition, cold drinks and applications to the affected parts and internal cooling (such as giving the patient lettuce) were recommended. Adams comments that Aetius has similarly recommended baths, unless putrefaction of 600 humours or inflammation of a vital organ was present; he then gave minute 594 Paul of Aegina, Epitome, 2, 34. In all cases, rubbing the body with oil before entering the bath, and with towels after exiting it, was advised. Similarly varied to treatment of fevers, the treatment of fainting varied significantly, depending on the identified causes; in some cases, bathing was discouraged altogether (which will be discussed later in the text). If the fainting was accompanied by cholera (interestingly, cholera seems to be a secondary problem here), with diarrhoea or vomiting, the physician was to further encourage vomiting; bathing the patient’s stomach with warm or hot water was to help during defluxions. However, caution was needed, as bathing would also aggravate any haemorrhages and sweating present. Similarly, the bathing was best avoided if the patient was fainting from plethora (defined as an excess of blood, or sanguine humour). Should the fainting be a result of a prolonged stay in a bath, though, the advice was to sprinkle the affected person with cold 601 water. If the fever was caused by exposure to cold, the body should be moderately warmed, and the head should be washed in the oil of iris and of nard. If the skin becomes constricted during the fever, bathing the patient in fresh, tepid water, along with rubbing, were advised. For fevers arising from hunger, the patient should be bathed after the first paroxysm had passed, and then a lot of tepid oil should be poured on the patient, which should be accompanied by gentle rubbing. For lethargy in general, which was described as arising from cold and humid phlegm affecting the brain, the Roman authors considered bathing beneficial during 603 convalescence. A Hippocratic caveat seems to have been omitted, though: even washing of the patient was discouraged for patients suffering from a particular form 604 of lethargy which resulted in patient’s death after seven days. Potential reasons for this omission may include lesser emphasis on case studies, or the anecdotal character of the Hippocratic remark; or it may have simply been left out for the sake of brevity. In addition, Aetius characterizes syncope as a form of fainting that can also take place in the sleep, and that is always accompanied by sweating. Galen’s additional suggestion was to bathe the patient in cold water, but only if the patients is strong. In some cases when bathing was allowed by Hippocratic texts, it was to 606 exclude washing of the head: for example, in the deadly “illness with hiccups” that is described as killing many patients on the seventh day from the onset of the 607 symptoms; similarly for patients suffering from tenesmus, and for cholera, where Hippocratic advice was to soften the body with medications and hot baths – but again, 608 without washing the head. Similarly, in case of high fever that might develop into pneumonia and can be potentially fatal, the patient ought to be bathed in hot water twice a day, but without the head – and not during crises or cleaning (which could 609 involve either emetics, laxatives or both). An illness with symptoms described as inflammation within the windpipe that caused a risk of suffocation (possibly croup), was to be treated in a following manner: if bloodletting did not bring immediate relief, then, among other things, physicians were advised to pour hot water on the feet of the patient. Paul included in the same chapter advice for treating strangulation it is interesting to note that the Hippocratic 611 aphorism suggesting the physician to refrain from attempts of saving the patient once part of the signs of life stop and foam appears at the mouth was brought up here, and the advice was repeated in a more direct way than in the original text. Hippocratic advice stated that for patients suffering from consumption, 612 bathing is either to be avoided completely or to be very rare and gentle – only 613 warm, not hot, water ought to be used, and the head should not be washed at all. In Internal affections, however, part of the treatment of a long-lasting consumption involved washing the patient every morning with a larger amount of hot water, and 605 Paul of Aegina, Epitome, 3, 39; De med. Paul’s advice on the treatment of gout and arthritis varied, depending on the humour that was believed to have caused the affliction: when it was from bilious humour, baths in drinking water were suggested, unless there were reasons other than defluxions to avoid bathing in general. If cold was the cause, frequent bathing should be avoided, and the patient should be rubbed with nitre and other unguents after the 615 bath. Galen suggested abstaining from warm baths, since while they provide 616 temporary relief, they tend to exacerbate the disease in the long run. Paul states strongly that while for the majority of cases of inflammation bathing in warm water is beneficial, it should be avoided when tendons are affected, and proposes bathing the affected place with thin, tepid and non-astringent oil. If the tendon was exposed, using oil should be avoided, and instead the area ought to be kept dry with soft wool wrapped around a probe. Bathing should be avoided for as long as the inflammation was present, but if the patient strongly desired to bathe, the affected body part should be prevented from coming in direct contact with water (cold even more so than hot). If the area was impossible to be kept dry during the bath, it should be protected by means of a thick, oiled compress and plasters; these multiple, protective layers should once again be coated in oil before the patient entered the bath. For injuries of tendons in which the 617 skin was not damaged, the affected body part was to be washed with warming oils. Paul devoted a separate chapter to the treatment of patients suffering from poisoning with cantharides (or, to use more correct terminology, Lytta vesicatoria, the Spanish fly). After the patient’s stomach and the bowels have been evacuated, he may be bathed in fresh water – but only at the later stages of the treatment, as bathing may 618 be harmful earlier on. As with almost all advice in his fifth book, Paul took this information from Dioscorides. Such approach increased the effectiveness of treatment and minimised unwanted side effects, and often indicated considerable experience (or thorough training) on the part of physicians. In Paul’s work, the general guidelines for bathing patients suffering from looseness of bowels caused by fevers were fairly simple: if the discharges were acrid, bathing was considered to be good, but only after the concoction (crisis, a turning point, usually a sudden one, in the course of a disease) took place. For patients with watery discharges, consisting of ‘phlegm’ abstaining from baths was deemed better, 619 unless their use was important for other reasons. Epilepsy was to be treated with, among other things, purges, followed by bathing; the patient, however, was advised to avoid frequent baths.

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