CURE OF BAD BREATH
Bad breath is a common health problem in the society.Offenssive smell from the mouth may be due to various reasons.The main reason is the presence of anaerobic bacteria in the biofilm formed on the tongue .These bacteria degrades the proteins present in the food resulting in the production of some offenssive gases like hydrogen sulphide,skatol ect.
Bad odor from the mouth in the early morning is seen in almost all individuals.This can be controlled by maintaining oral hygiene.Even after cleaning the mouth some individuals may suffer from bad breath due to some problem in the mouth or in the nearby areas.Some general disease condition can also produce bad breath.Exact cause has to be identified and should be treated accordingly.Some common measures to cure or reduce bad breath are discussed here.
1) Oral hygiene:
Mouth should be kept clean every time to reduce the bacterial action.After food gargling with lukewarm water is very essential.Even after small food articles like snacks,sweets,buscuits cleaning with water is needed.Brushing should be done twice daily.It is said that early morning brushing is for beauty and bed time brushing is for good health.
2) Brushing techniques:
Normal brushing technique should be followed for better result.Many people brush vigorously causing damage to the gums.Brushing after every food and drink can damage the enamel .Bristles of the tooth brush should be smooth but hard enough to remove the food particles from the gaps.The direction of brushing is the most important thing.The upper teeth should be brushed in a downward direction and the lower in upward direction.This is applicable to both inner and outer surfaces.Next comes the crown of the teeth;here brushing is done in anterior and posterior direction keeping the brush in same direction.This applicable to both upper and lower set of teeth.
3) Tongue cleaning:
White or yellowish coating on the tongue can cause bad breath.This is more well marked in the morning and should be removed twice daily with the healp of a tongue cleaner. Tongue cleaner must be used gently without damaging the taste buds on the tongue.
4) Tooth pick:
Tooth pick is a small strip of wood or plastic with a pointed end.This is used to remove food particles lodged between the gaps.Very useful after eating meat and fish.Should be used gently to avoid damage to gums.
5) Gargling:
After every meal gargling with lukewarm water is useful.For better result little common salt is dissolved in the lukewarm water .Different types of mouth wash is available in the market in different trade names.Gargling with mouth wash can also reduce bad breath.
6) Food habits:
Protein containing food articles are known to produce bad breath. Example; meat, milk, fish, egg etc. If these food articles are taken proper cleaning is essential.Some food articles are known to produce particular smell which may be unpleasent for others. Raw onion is the best example.It is said that an apple a day keeps the doctor away and a raw onion a day keep every body away.Small food articles taken in between can also cause bad smell(nuts,fried items etc).Maintaining regularity in food timing is the most important thing.
7) Water intake:
Dryness in the mouth can make a favourable condition for the bacterial activity resulting in bad odor.saliva is needed to keep the mouth moist and to reduce the bacterial proliferation.Production of saliva is closely related with water balance of the body and hence sufficient quantity of water should be taken to maintain the production of saliva.
8) Mouth freshners:
Natural and artificial mouth freshners can reduce the intensity of bad breath to some extent.Spicy articles are commonly used for this purpose.Chewing spices like clove,cumin seed,cardomom,cinnamon,ginger ect are useful. All citrus fruits can reduce bad odor.Mouth freshners and chewing gums are available in the market.these products are also helpful ,but some may cause damage hence should be used with caution.
If the above things doesn't work then what to do ?
Consider the following:-
1) Remove the cause:
Bad breath is common in some general and systemic diseases like diabetes,fevers,gastric disorders,liver diseases and ect.By removing or reducing the primary cause the bad breath will go automatically.
2) Modern medicine:
If bad breath is due to any infection suitable antibiotics,anti fungal or anti viral medicines will help.If it is due to any autoimmune or chronic inflamatory conditions steroids may also be used.Saliva producing tablets can also be used.
3) Dental cleaning:
Dental cleaning done by a dentist can remove the dental plaques and tartar. This can reduce the severity of bad breath.Visit your dentist atleast once in a year.
4) Filling of caries:
Since caries are one of the main cause for bad breath it should be filled by a dentist.Earlier silver amalgam was used ,nowadays it is replaced by synthetic materials.If the pulp cavity is affected by the caries root canal treatment can be done.
5) Tooth extraction:
If caries are deep with destruction of teeth with bad smell extraction is the better choice and a dental implant can be kept in the gap.
6) Tonsillectomy:
Patients with recurrent tonsillitis can have bad breath due to offenssive discharges and release of pasty materials from the crypts of tonsils.Such patients get great relief after tonsillectomy(removal of tonsils).
7) Psychological counselling:
Those who suffer from bad breath may be very much depressed and they be away from the public .This isolation hampers their daytoday activities.Such people should understand the fact that all humanbeings are having bad breath, but with slight differences in intensities.Mostly all people control it by taking personal care.Every human body has got it's own smell,that may or may not be tolerable for others.They should be adviced to do all hygienic meashures to reduce the intensity of smell.Improving the quality of life by all possible means can also help.Moral support from friends and family members are needed for such people.
Some individuals visit the doctor for bad breath without any real problem.It is included under somatisation disorder.They usually complain about pain, breathlessness,abdominal discomfort,bad smell ect.proper diagnosis is needed to rule out any real causes.These patients should be managed with a psychological approach.
8) Homoeopathy:
In Homoeopathy medicines are selected on the basis of physical ,mental,emotional,and social aspects of the diseased person.Considering the whole aspects a constitutional homoeopathic medicine is selected and given in suitable potency and dose.By this all health related problems including bad breath will be solved.On the basis of coating on the tongue,type of smell,cause for bad breath,and other associated complaints a medicine can be given to get relief from bad breath.In the homoeopathic medical repertory by Dr Robin Murphy there are 140 homoeopathic drugs mentioned for bad breath.On the basis of signs and symptoms of the individual a suitable medicine is given.Commonly used drugs are arnica, antim crud, pulsatilla, sulphur, psorinum, nux vomica, ars alb, merc sol, kreosot, hekla lava, silicea, asafoitida, graphites, kali bich, acid nitric etc.
Homoeopathic mother tinctures like cinnamon Q,kreosot Q,zingiber Q,rhus glabra Q,menthol Q and ect can be used for gargling after diluting in water.
[POINTS MENTIONED IN THIS ARTICLE IS FOR GENERAL AWARENESS. ANY BODY SUFFERING FROM BAD BREATH SHOULD CONSULT A DOCTOR.]
Tuesday, April 16, 2013
Sunday, April 14, 2013
CAUSES OF LOW BACK PAIN.
CAUSES OF LOW BACK PAIN.
Low back pain is a usual symptom amoung the modern civilised people.It affects mainly the middle aged and young adults of both sexes.People who work on the chair with out exercise and those who carry heavy loads regularly are prone to get this complaint.We can hardly find a person who has not suffered from back pain atleast once in life.The causes of low backpain ranges from simple reasons like muscular strain to cancer of spine and hence backache should not be ignored.The pain is felt in lumbar and sacral region and may radiate to nearby sites.
The following are some causes for backache.
1) Backache due to diseases in the back.
2) Backache due to gynaecological problems.
3) Backache due to problems in other parts of the body.
1) Backache due to diseases in the back:--
a) Injuries :-
1) Compression fracture of the vertebral column.
2) Rupture of intervertebral discs.
3) Injuries to ligaments and muscles of back.
4) Lumbosacral strain.
5) Intervertebral joint injuries.
6) Fracture of processes of vertebra.
b) Functional backache due to imbalance:-
1) During pregnancy.
2) Pot belly.
3) Diseases of the hip joint.
4) Curvature in the spine due to congenital defect.
5) Short leg in one side.
c) Backache due to inflammatory conditions:-
1) Infection of the bone due to bacteria.
2) Tuberculosis of the spine.
3) Arthritis.
4) Brucellosis.
5) Lumbago or fibrositis.
6) Inflamation of the muscles.
7) Anchylosing spondylitis.
d) Backache due to degenerative diseases in the back.
1) Osteoarthritis.
2) Osteoporosis in old people.
3) Degenaration of the intervertebral disc.
e) Tumour in the spine:--
1) Primory tumour of the bones in the spine.
2) Metastatic tumours from other sites like prostate,lungs,kidneys,intestine ect.
2) Backache due to gynaecological problems:-
a) After childbirth.
b) After gynaecological operations.
c) Prolapse of the uterus.
d) Pelvic inflammatory diseases.
e) Cancerous lesions of the pelvic organs.
f) Endometriosis.
3) Backache due to problems in other parts of the body.
a) Renal stones.
b) Ureteric stone.
c) Cancer of prostate.
d) Pancreatitis.
e) Biliary stones.
f) Peptic ulcer.
g) Inflammations of pelvic organs.
h) Occlusion of aorta and illiac arteries.
Investigation of a case of backache:-
1) Complete blood count.
2) Routine urine examination.
3) Ultrasonography of the abdomen and pelvis.
4) X-ray of the lumbar and sacral region.
5) MRI of the spine.
5) CT scan of abdomen and pelvic region.
6) Examination of rectum,prostate,genito urinary organs.
Treatment of back ache:-
1) Removing the cause for backache.
2) Symptomatic treatement.
2) Back exercises.
3) Traction.
3) Yoga.
5) Surgery.
7) Homoeopathy.
Low back pain is a usual symptom amoung the modern civilised people.It affects mainly the middle aged and young adults of both sexes.People who work on the chair with out exercise and those who carry heavy loads regularly are prone to get this complaint.We can hardly find a person who has not suffered from back pain atleast once in life.The causes of low backpain ranges from simple reasons like muscular strain to cancer of spine and hence backache should not be ignored.The pain is felt in lumbar and sacral region and may radiate to nearby sites.
The following are some causes for backache.
1) Backache due to diseases in the back.
2) Backache due to gynaecological problems.
3) Backache due to problems in other parts of the body.
1) Backache due to diseases in the back:--
a) Injuries :-
1) Compression fracture of the vertebral column.
2) Rupture of intervertebral discs.
3) Injuries to ligaments and muscles of back.
4) Lumbosacral strain.
5) Intervertebral joint injuries.
6) Fracture of processes of vertebra.
b) Functional backache due to imbalance:-
1) During pregnancy.
2) Pot belly.
3) Diseases of the hip joint.
4) Curvature in the spine due to congenital defect.
5) Short leg in one side.
c) Backache due to inflammatory conditions:-
1) Infection of the bone due to bacteria.
2) Tuberculosis of the spine.
3) Arthritis.
4) Brucellosis.
5) Lumbago or fibrositis.
6) Inflamation of the muscles.
7) Anchylosing spondylitis.
d) Backache due to degenerative diseases in the back.
1) Osteoarthritis.
2) Osteoporosis in old people.
3) Degenaration of the intervertebral disc.
e) Tumour in the spine:--
1) Primory tumour of the bones in the spine.
2) Metastatic tumours from other sites like prostate,lungs,kidneys,intestine ect.
2) Backache due to gynaecological problems:-
a) After childbirth.
b) After gynaecological operations.
c) Prolapse of the uterus.
d) Pelvic inflammatory diseases.
e) Cancerous lesions of the pelvic organs.
f) Endometriosis.
3) Backache due to problems in other parts of the body.
a) Renal stones.
b) Ureteric stone.
c) Cancer of prostate.
d) Pancreatitis.
e) Biliary stones.
f) Peptic ulcer.
g) Inflammations of pelvic organs.
h) Occlusion of aorta and illiac arteries.
Investigation of a case of backache:-
1) Complete blood count.
2) Routine urine examination.
3) Ultrasonography of the abdomen and pelvis.
4) X-ray of the lumbar and sacral region.
5) MRI of the spine.
5) CT scan of abdomen and pelvic region.
6) Examination of rectum,prostate,genito urinary organs.
Treatment of back ache:-
1) Removing the cause for backache.
2) Symptomatic treatement.
2) Back exercises.
3) Traction.
3) Yoga.
5) Surgery.
7) Homoeopathy.
Saturday, April 13, 2013
ALCOHOL HAS NO FOOD VALUE.
ALCOHOL HAS NO FOOD VALUE.
Alcohol has no food value and is exceedingly limited in its action as a remedial agent. Dr. Henry Monroe says, "every kind of substance employed by man as food consists of sugar, starch, oil and glutinous matter mingled together in various proportions. These are designed for the support of the animal frame. The glutinous principles of food fibrine, albumen and casein are employed to build up the structure while the oil, starch and sugar are chiefly used to generate heat in the body".
Now it is clear that if alcohol is a food, it will be found to contain one or more of these substances. There must be in it either the nitrogenous elements found chiefly in meats, eggs, milk, vegetables and seeds, out of which animal tissue is built and waste repaired or the carbonaceous elements found in fat, starch and sugar, in the consumption of which heat and force are evolved.
"The distinctness of these groups of foods," says Dr. Hunt, "and their relations to the tissue-producing and heat-evolving capacities of man, are so definite and so confirmed by experiments on animals and by manifold tests of scientific, physiological and clinical experience, that no attempt to discard the classification has prevailed. To draw so straight a line of demarcation as to limit the one entirely to tissue or cell production and the other to heat and force production through ordinary combustion and to deny any power of interchangeability under special demands or amid defective supply of one variety is, indeed, untenable. This does not in the least invalidate the fact that we are able to use these as ascertained landmarks".
How these substances when taken into the body, are assimilated and how they generate force, are well known to the chemist and physiologist, who is able, in the light of well-ascertained laws, to determine whether alcohol does or does not possess a food value. For years, the ablest men in the medical profession have given this subject the most careful study, and have subjected alcohol to every known test and experiment, and the result is that it has been, by common consent, excluded from the class of tissue-building foods. "We have never," says Dr. Hunt, "seen but a single suggestion that it could so act, and this a promiscuous guess. One writer (Hammond) thinks it possible that it may 'somehow' enter into combination with the products of decay in tissues, and 'under certain circumstances might yield their nitrogen to the construction of new tissues.' No parallel in organic chemistry, nor any evidence in animal chemistry, can be found to surround this guess with the areola of a possible hypothesis".
Dr. Richardson says: "Alcohol contains no nitrogen; it has none of the qualities of structure-building foods; it is incapable of being transformed into any of them; it is, therefore, not a food in any sense of its being a constructive agent in building up the body." Dr. W.B. Carpenter says: "Alcohol cannot supply anything which is essential to the true nutrition of the tissues." Dr. Liebig says: "Beer, wine, spirits, etc., furnish no element capable of entering into the composition of the blood, muscular fibre, or any part which is the seat of the principle of life." Dr. Hammond, in his Tribune Lectures, in which he advocates the use of alcohol in certain cases, says: "It is not demonstrable that alcohol undergoes conversion into tissue." Cameron, in his Manuel of Hygiene, says: "There is nothing in alcohol with which any part of the body can be nourished." Dr. E. Smith, F.R.S., says: "Alcohol is not a true food. It interferes with alimentation." Dr. T.K. Chambers says: "It is clear that we must cease to regard alcohol, as in any sense, a food".
"Not detecting in this substance," says Dr. Hunt, "any tissue-making ingredients, nor in its breaking up any combinations, such as we are able to trace in the cell foods, nor any evidence either in the experience of physiologists or the trials of alimentarians, it is not wonderful that in it we should find neither the expectancy nor the realization of constructive power."
Not finding in alcohol anything out of which the body can be built up or its waste supplied, it is next to be examined as to its heat-producing quality.
Production of heat.
------------------
"The first usual test for a force-producing food," says Dr. Hunt, "and that to which other foods of that class respond, is the production of heat in the combination of oxygen therewith. This heat means vital force, and is, in no small degree, a measure of the comparative value of the so-called respiratory foods. If we examine the fats, the starches and the sugars, we can trace and estimate the processes by which they evolve heat and are changed into vital force, and can weigh the capacities of different foods. We find that the consumption of carbon by union with oxygen is the law, that heat is the product, and that the legitimate result is force, while the result of the union of the hydrogen of the foods with oxygen is water. If alcohol comes at all under this class of foods, we rightly expect to find some of the evidences which attach to the hydrocarbons."
What, then, is the result of experiments in this direction? They have been conducted through long periods and with the greatest care, by men of the highest attainments in chemistry and physiology, and the result is given in these few words, by Dr. H.R. Wood, Jr., in his Materia Medica. "No one has been able to detect in the blood any of the ordinary results of its oxidation." That is, no one has been able to find that alcohol has undergone combustion, like fat, or starch, or sugar, and so given heat to the body.
Alcohol and reduction of temperature.
------------------------------------
instead of increasing it; and it has even been used in fevers as an anti-pyretic. So uniform has been the testimony of physicians in Europe and America as to the cooling effects of alcohol, that Dr. Wood says, in his Materia Medica, "that it does not seem worth while to occupy space with a discussion of the subject." Liebermeister, one of the most learned contributors to Zeimssen's Cyclopaedia of the Practice of Medicine, 1875, says: "I long since convinced myself, by direct experiments, that alcohol, even in comparatively large doses, does not elevate the temperature of the body in either well or sick people." So well had this become known to Arctic voyagers, that, even before physiologists had demonstrated the fact that alcohol reduced, instead of increasing, the temperature of the body, they had learned that spirits lessened their power to withstand extreme cold. "In the Northern regions," says Edward Smith, "it was proved that the entire exclusion of spirits was necessary, in order to retain heat under these unfavorable conditions."
Alcohol does not make you strong.
--------------------------------
If alcohol does not contain tissue-building material, nor give heat to the body, it cannot possibly add to its strength. "Every kind of power an animal can generate," says Dr. G. Budd, F.R.S., "the mechanical power of the muscles, the chemical (or digestive) power of the stomach, the intellectual power of the brain accumulates through the nutrition of the organ on which it depends." Dr. F.R. Lees, of Edinburgh, after discussing the question, and educing evidence, remarks: "From the very nature of things, it will now be seen how impossible it is that alcohol can be strengthening food of either kind. Since it cannot become a part of the body, it cannot consequently contribute to its cohesive, organic strength, or fixed power; and, since it comes out of the body just as it went in, it cannot, by its decomposition, generate heat force."
Sir Benjamin Brodie says: "Stimulants do not create nervous power; they merely enable you, as it were, to use up that which is left, and then they leave you more in need of rest than before."
Baron Liebig, so far back as 1843, in his "Animal Chemistry," pointed out the fallacy of alcohol generating power. He says: "The circulation will appear accelerated at the expense of the force available for voluntary motion, but without the production of a greater amount of mechanical force." In his later "Letters," he again says: "Wine is quite superfluous to man, it is constantly followed by the expenditure of power" whereas, the real function of food is to give power. He adds: "These drinks promote the change of matter in the body, and are, consequently, attended by an inward loss of power, which ceases to be productive, because it is not employed in overcoming outward difficulties i.e., in working." In other words, this great chemist asserts that alcohol abstracts the power of the system from doing useful work in the field or workshop, in order to cleanse the house from the defilement of alcohol itself.
The late Dr. W. Brinton, Physician to St. Thomas', in his great work on Dietetics, says: "Careful observation leaves little doubt that a moderate dose of beer or wine would, in most cases, at once diminish the maximum weight which a healthy person could lift. Mental acuteness, accuracy of perception and delicacy of the senses are all so far opposed by alcohol, as that the maximum efforts of each are incompatible with the ingestion of any moderate quantity of fermented liquid. A single glass will often suffice to take the edge off both mind and body, and to reduce their capacity to something below their perfection of work."
Dr. F.R. Lees, F.S.A., writing on the subject of alcohol as a food, makes the following quotation from an essay on "Stimulating Drinks," published by Dr. H.R. Madden, as long ago as 1847: "Alcohol is not the natural stimulus to any of our organs, and hence, functions performed in consequence of its application, tend to debilitate the organ acted upon.
Alcohol is incapable of being assimilated or converted into any organic proximate principle, and hence, cannot be considered nutritious.
The strength experienced after the use of alcohol is not new strength added to the system, but is manifested by calling into exercise the nervous energy pre-existing.
The ultimate exhausting effects of alcohol, owing to its stimulant properties, produce an unnatural susceptibility to morbid action in all the organs, and this, with the plethora superinduced, becomes a fertile source of disease.
A person who habitually exerts himself to such an extent as to require the daily use of stimulants to ward off exhaustion, may be compared to a machine working under high pressure. He will become much more obnoxious to the causes of disease, and will certainly break down sooner than he would have done under more favorable circumstances.
The more frequently alcohol is had recourse to for the purpose of overcoming feelings of debility, the more it will be required, and by constant repetition a period is at length reached when it cannot be foregone, unless reaction is simultaneously brought about by a temporary total change of the habits of life.
Driven to the wall.
------------------
Not finding that alcohol possesses any direct alimentary value, the medical advocates of its use have been driven to the assumption that it is a kind of secondary food, in that it has the power to delay the metamorphosis of tissue. "By the metamorphosis of tissue is meant," says Dr. Hunt, "that change which is constantly going on in the system which involves a constant disintegration of material; a breaking up and avoiding of that which is no longer aliment, making room for that new supply which is to sustain life." Another medical writer, in referring to this metamorphosis, says: "The importance of this process to the maintenance of life is readily shown by the injurious effects which follow upon its disturbance. If the discharge of the excrementitious substances be in any way impeded or suspended, these substances accumulate either in the blood or tissues, or both. In consequence of this retention and accumulation they become poisonous, and rapidly produce a derangement of the vital functions. Their influence is principally exerted upon the nervous system, through which they produce most frequent irritability, disturbance of the special senses, delirium, insensibility, coma, and finally, death."
"This description," remarks Dr. Hunt, "seems almost intended for alcohol." He then says: "To claim alcohol as a food because it delays the metamorphosis of tissue, is to claim that it in some way suspends the normal conduct of the laws of assimilation and nutrition, of waste and repair. A leading advocate of alcohol (Hammond) thus illustrates it: 'Alcohol retards the destruction of the tissues. By this destruction, force is generated, muscles contract, thoughts are developed, organs secrete and excrete.' In other words, alcohol interferes with all these. No wonder the author 'is not clear' how it does this, and we are not clear how such delayed metamorphosis recuperates.
Not an originator of vital force.
--------------------------------
which is not known to have any of the usual power of foods, and use it on the double assumption that it delays metamorphosis of tissue, and that such delay is conservative of health, is to pass outside of the bounds of science into the land of remote possibilities, and confer the title of adjuster upon an agent whose agency is itself doubtful.
Having failed to identify alcohol as a nitrogenous or non-nitrogenous food, not having found it amenable to any of the evidences by which the food-force of aliments is generally measured, it will not do for us to talk of benefit by delay of regressive metamorphosis unless such process is accompanied with something evidential of the fact something scientifically descriptive of its mode of accomplishment in the case at hand, and unless it is shown to be practically desirable for alimentation.
There can be no doubt that alcohol does cause defects in the processes of elimination which are natural to the healthy body and which even in disease are often conservative of health.
Alcohol has no food value and is exceedingly limited in its action as a remedial agent. Dr. Henry Monroe says, "every kind of substance employed by man as food consists of sugar, starch, oil and glutinous matter mingled together in various proportions. These are designed for the support of the animal frame. The glutinous principles of food fibrine, albumen and casein are employed to build up the structure while the oil, starch and sugar are chiefly used to generate heat in the body".
Now it is clear that if alcohol is a food, it will be found to contain one or more of these substances. There must be in it either the nitrogenous elements found chiefly in meats, eggs, milk, vegetables and seeds, out of which animal tissue is built and waste repaired or the carbonaceous elements found in fat, starch and sugar, in the consumption of which heat and force are evolved.
"The distinctness of these groups of foods," says Dr. Hunt, "and their relations to the tissue-producing and heat-evolving capacities of man, are so definite and so confirmed by experiments on animals and by manifold tests of scientific, physiological and clinical experience, that no attempt to discard the classification has prevailed. To draw so straight a line of demarcation as to limit the one entirely to tissue or cell production and the other to heat and force production through ordinary combustion and to deny any power of interchangeability under special demands or amid defective supply of one variety is, indeed, untenable. This does not in the least invalidate the fact that we are able to use these as ascertained landmarks".
How these substances when taken into the body, are assimilated and how they generate force, are well known to the chemist and physiologist, who is able, in the light of well-ascertained laws, to determine whether alcohol does or does not possess a food value. For years, the ablest men in the medical profession have given this subject the most careful study, and have subjected alcohol to every known test and experiment, and the result is that it has been, by common consent, excluded from the class of tissue-building foods. "We have never," says Dr. Hunt, "seen but a single suggestion that it could so act, and this a promiscuous guess. One writer (Hammond) thinks it possible that it may 'somehow' enter into combination with the products of decay in tissues, and 'under certain circumstances might yield their nitrogen to the construction of new tissues.' No parallel in organic chemistry, nor any evidence in animal chemistry, can be found to surround this guess with the areola of a possible hypothesis".
Dr. Richardson says: "Alcohol contains no nitrogen; it has none of the qualities of structure-building foods; it is incapable of being transformed into any of them; it is, therefore, not a food in any sense of its being a constructive agent in building up the body." Dr. W.B. Carpenter says: "Alcohol cannot supply anything which is essential to the true nutrition of the tissues." Dr. Liebig says: "Beer, wine, spirits, etc., furnish no element capable of entering into the composition of the blood, muscular fibre, or any part which is the seat of the principle of life." Dr. Hammond, in his Tribune Lectures, in which he advocates the use of alcohol in certain cases, says: "It is not demonstrable that alcohol undergoes conversion into tissue." Cameron, in his Manuel of Hygiene, says: "There is nothing in alcohol with which any part of the body can be nourished." Dr. E. Smith, F.R.S., says: "Alcohol is not a true food. It interferes with alimentation." Dr. T.K. Chambers says: "It is clear that we must cease to regard alcohol, as in any sense, a food".
"Not detecting in this substance," says Dr. Hunt, "any tissue-making ingredients, nor in its breaking up any combinations, such as we are able to trace in the cell foods, nor any evidence either in the experience of physiologists or the trials of alimentarians, it is not wonderful that in it we should find neither the expectancy nor the realization of constructive power."
Not finding in alcohol anything out of which the body can be built up or its waste supplied, it is next to be examined as to its heat-producing quality.
Production of heat.
------------------
"The first usual test for a force-producing food," says Dr. Hunt, "and that to which other foods of that class respond, is the production of heat in the combination of oxygen therewith. This heat means vital force, and is, in no small degree, a measure of the comparative value of the so-called respiratory foods. If we examine the fats, the starches and the sugars, we can trace and estimate the processes by which they evolve heat and are changed into vital force, and can weigh the capacities of different foods. We find that the consumption of carbon by union with oxygen is the law, that heat is the product, and that the legitimate result is force, while the result of the union of the hydrogen of the foods with oxygen is water. If alcohol comes at all under this class of foods, we rightly expect to find some of the evidences which attach to the hydrocarbons."
What, then, is the result of experiments in this direction? They have been conducted through long periods and with the greatest care, by men of the highest attainments in chemistry and physiology, and the result is given in these few words, by Dr. H.R. Wood, Jr., in his Materia Medica. "No one has been able to detect in the blood any of the ordinary results of its oxidation." That is, no one has been able to find that alcohol has undergone combustion, like fat, or starch, or sugar, and so given heat to the body.
Alcohol and reduction of temperature.
------------------------------------
instead of increasing it; and it has even been used in fevers as an anti-pyretic. So uniform has been the testimony of physicians in Europe and America as to the cooling effects of alcohol, that Dr. Wood says, in his Materia Medica, "that it does not seem worth while to occupy space with a discussion of the subject." Liebermeister, one of the most learned contributors to Zeimssen's Cyclopaedia of the Practice of Medicine, 1875, says: "I long since convinced myself, by direct experiments, that alcohol, even in comparatively large doses, does not elevate the temperature of the body in either well or sick people." So well had this become known to Arctic voyagers, that, even before physiologists had demonstrated the fact that alcohol reduced, instead of increasing, the temperature of the body, they had learned that spirits lessened their power to withstand extreme cold. "In the Northern regions," says Edward Smith, "it was proved that the entire exclusion of spirits was necessary, in order to retain heat under these unfavorable conditions."
Alcohol does not make you strong.
--------------------------------
If alcohol does not contain tissue-building material, nor give heat to the body, it cannot possibly add to its strength. "Every kind of power an animal can generate," says Dr. G. Budd, F.R.S., "the mechanical power of the muscles, the chemical (or digestive) power of the stomach, the intellectual power of the brain accumulates through the nutrition of the organ on which it depends." Dr. F.R. Lees, of Edinburgh, after discussing the question, and educing evidence, remarks: "From the very nature of things, it will now be seen how impossible it is that alcohol can be strengthening food of either kind. Since it cannot become a part of the body, it cannot consequently contribute to its cohesive, organic strength, or fixed power; and, since it comes out of the body just as it went in, it cannot, by its decomposition, generate heat force."
Sir Benjamin Brodie says: "Stimulants do not create nervous power; they merely enable you, as it were, to use up that which is left, and then they leave you more in need of rest than before."
Baron Liebig, so far back as 1843, in his "Animal Chemistry," pointed out the fallacy of alcohol generating power. He says: "The circulation will appear accelerated at the expense of the force available for voluntary motion, but without the production of a greater amount of mechanical force." In his later "Letters," he again says: "Wine is quite superfluous to man, it is constantly followed by the expenditure of power" whereas, the real function of food is to give power. He adds: "These drinks promote the change of matter in the body, and are, consequently, attended by an inward loss of power, which ceases to be productive, because it is not employed in overcoming outward difficulties i.e., in working." In other words, this great chemist asserts that alcohol abstracts the power of the system from doing useful work in the field or workshop, in order to cleanse the house from the defilement of alcohol itself.
The late Dr. W. Brinton, Physician to St. Thomas', in his great work on Dietetics, says: "Careful observation leaves little doubt that a moderate dose of beer or wine would, in most cases, at once diminish the maximum weight which a healthy person could lift. Mental acuteness, accuracy of perception and delicacy of the senses are all so far opposed by alcohol, as that the maximum efforts of each are incompatible with the ingestion of any moderate quantity of fermented liquid. A single glass will often suffice to take the edge off both mind and body, and to reduce their capacity to something below their perfection of work."
Dr. F.R. Lees, F.S.A., writing on the subject of alcohol as a food, makes the following quotation from an essay on "Stimulating Drinks," published by Dr. H.R. Madden, as long ago as 1847: "Alcohol is not the natural stimulus to any of our organs, and hence, functions performed in consequence of its application, tend to debilitate the organ acted upon.
Alcohol is incapable of being assimilated or converted into any organic proximate principle, and hence, cannot be considered nutritious.
The strength experienced after the use of alcohol is not new strength added to the system, but is manifested by calling into exercise the nervous energy pre-existing.
The ultimate exhausting effects of alcohol, owing to its stimulant properties, produce an unnatural susceptibility to morbid action in all the organs, and this, with the plethora superinduced, becomes a fertile source of disease.
A person who habitually exerts himself to such an extent as to require the daily use of stimulants to ward off exhaustion, may be compared to a machine working under high pressure. He will become much more obnoxious to the causes of disease, and will certainly break down sooner than he would have done under more favorable circumstances.
The more frequently alcohol is had recourse to for the purpose of overcoming feelings of debility, the more it will be required, and by constant repetition a period is at length reached when it cannot be foregone, unless reaction is simultaneously brought about by a temporary total change of the habits of life.
Driven to the wall.
------------------
Not finding that alcohol possesses any direct alimentary value, the medical advocates of its use have been driven to the assumption that it is a kind of secondary food, in that it has the power to delay the metamorphosis of tissue. "By the metamorphosis of tissue is meant," says Dr. Hunt, "that change which is constantly going on in the system which involves a constant disintegration of material; a breaking up and avoiding of that which is no longer aliment, making room for that new supply which is to sustain life." Another medical writer, in referring to this metamorphosis, says: "The importance of this process to the maintenance of life is readily shown by the injurious effects which follow upon its disturbance. If the discharge of the excrementitious substances be in any way impeded or suspended, these substances accumulate either in the blood or tissues, or both. In consequence of this retention and accumulation they become poisonous, and rapidly produce a derangement of the vital functions. Their influence is principally exerted upon the nervous system, through which they produce most frequent irritability, disturbance of the special senses, delirium, insensibility, coma, and finally, death."
"This description," remarks Dr. Hunt, "seems almost intended for alcohol." He then says: "To claim alcohol as a food because it delays the metamorphosis of tissue, is to claim that it in some way suspends the normal conduct of the laws of assimilation and nutrition, of waste and repair. A leading advocate of alcohol (Hammond) thus illustrates it: 'Alcohol retards the destruction of the tissues. By this destruction, force is generated, muscles contract, thoughts are developed, organs secrete and excrete.' In other words, alcohol interferes with all these. No wonder the author 'is not clear' how it does this, and we are not clear how such delayed metamorphosis recuperates.
Not an originator of vital force.
--------------------------------
which is not known to have any of the usual power of foods, and use it on the double assumption that it delays metamorphosis of tissue, and that such delay is conservative of health, is to pass outside of the bounds of science into the land of remote possibilities, and confer the title of adjuster upon an agent whose agency is itself doubtful.
Having failed to identify alcohol as a nitrogenous or non-nitrogenous food, not having found it amenable to any of the evidences by which the food-force of aliments is generally measured, it will not do for us to talk of benefit by delay of regressive metamorphosis unless such process is accompanied with something evidential of the fact something scientifically descriptive of its mode of accomplishment in the case at hand, and unless it is shown to be practically desirable for alimentation.
There can be no doubt that alcohol does cause defects in the processes of elimination which are natural to the healthy body and which even in disease are often conservative of health.
Friday, April 12, 2013
NAILS IN HEALTH AND DISEASE.
NAILS IN HEALTH AND DISEASE.
Introduction:
The nails are present at the end of each finger tip on the dorsal surface.The main function of nail is protection and it also helps for a firm grip for holding articles.It consists of a strong relatively flexible keratinous nail plate originating from the nail matrix. Under the nail plate there is a soft tissue called nail bed.Between the skin and nail plate there is a nail fold or cuticle.Normal healthy nail is slight pink in colour and the surface is convex from side to side.Finger nails grow 1 cm in three months and toe nails take 24 months for the same.
Importance of nails in disease diagnosis:
The colour ,appearance,shape and nature of the nails give some information about the general health and hygiene of a person . Nails are examined as a routine by all doctors to get some clues about underlying diseases.Just looking at nails we can makeout the hygiene of a person.The abnormal nail may be congenital or due to some diseases.The cause for changes in the nail extend from simple reasons to life threatening diseases.Hence the examination by a doctor is essential for diagnosis .Some abnormal findings with probable causes are discussed here for general awareness.
1) Hygiene:-
We can make out an unhygienic nail very easily .Deposition of dirt under the distal end of nail plate can make a chance for ingestion of pathogens while eating.If nail cutting is not done properly it can result in worm troubles in children.When the worms crawl in the anal orifice children will scratch which lodges the ova of worms under the nails and will be taken in while eating.Prominent nail can also complicate a skin disease by habitual scratching.Sharp nails in small kids cause small wounds when they do feet kicking or hand waving.
2) Colour of the nails:-
a) Nails become pale in anaemia.
b) Opaque white discolouration(leuconychia) is seen in chronic renal failure and nephrotic syndrome.
c) Whitening is also seen in hypoalbuminaemia as in cirrhosis and kidney disorders.
d) Drugs like sulpha group,anti malarial and antibiotics ect can produce discolouration in the nails.
e) Fungal infection causes black discolouration.
f) In pseudomonas infection nails become black or green.
g) Nail bed infarction occures in vasculitis especially in SLE and polyarteritis.
h) Red dots are seen in nails due to splinter haemorrhages in subacute bacterial endo carditis, rheumatoid arthritis, trauma, collagen vascular diseases.
i) Blunt injury produces haemorrhage and causes blue/black discolouration.
j) Nails become brown in kidney diseases and in decreased adrenal activity.
k) In wilsons disease blue colour in semicircle appears in the nail.
l) When the blood supply decreases nail become yellow .In jaundice and psoriasis also nail become yellowish.
m) In yellow nail syndrome all nails become yellowish with pleural effusion.
3) Shape of nails:-
a) Clubbing: Here tissues at the base of nails are thickened and the angle between the nail base and the skin is obliterated. The nail becomes more convex and the finger tip becomes bulbous and looks like an end of a drumstick. When the condition becomes worse the nail looks like a parrot beak.
Causes of clubbing:-
Congenital Injuries
Severe chronic cyanosis
Lung diseases like empyema,bronchiactesis,carcinoma of bronchus and pulmonary tuberculosis.
Abdominal diseases like crohn's disease,polyposis of colon,ulcerative colitis,liver cirrhosis ect...
Heart diseases like fallot's tetralogy,subacute bacterial endocarditis and ect..
b) Koilonychia:-
Here the nails become concave like a spoon.This condition is seen in iron deficiency anaemia.In this condition the nails become thin,soft and brittle.The normal convexity will be replaced by concavity.
c) Longitudinal ridging is seen in raynaud's disease.
d) Cuticle becomes ragged in dermatomyositis.
e) Nail fold telangiectasia is a sign in dermatomyositis ,systemic sclerosis and SLE.
4) Structure and consistancy:-
a) Fungal infection of nail causes discolouration,deformity,hypertrophy and abnormal brittleness.
b) Thimble pitting of nail is charecteristic of psoriasis ,acute eczema and alopecia aereata.
c) The inflamation of cuticle or nail fold is called paronychia.
d) Onycholysis is the seperation of nail bed seen in psoriasis,infection and after taking tetracyclines.
e) Destruction of nail is seen in lichen planus,epidermolysis bullosa.
f) Missing nail is seen in nail patella syndrome.It is a hereditary disease.
g) Nails become brittle in raynauds disease and gangrene.
h) Falling of nail is seen in fungal infection,psoriasis and thyroid diseases.
5) Growth:-
Reduction in blood supply affects the growth of nails. Nail growth is also affected in severe ilness. when the disease disappears the growth starts again resulting in formation of transverse ridges.These lines are called Beau's lines and are healpful to date the onset of illness.
Introduction:
The nails are present at the end of each finger tip on the dorsal surface.The main function of nail is protection and it also helps for a firm grip for holding articles.It consists of a strong relatively flexible keratinous nail plate originating from the nail matrix. Under the nail plate there is a soft tissue called nail bed.Between the skin and nail plate there is a nail fold or cuticle.Normal healthy nail is slight pink in colour and the surface is convex from side to side.Finger nails grow 1 cm in three months and toe nails take 24 months for the same.
Importance of nails in disease diagnosis:
The colour ,appearance,shape and nature of the nails give some information about the general health and hygiene of a person . Nails are examined as a routine by all doctors to get some clues about underlying diseases.Just looking at nails we can makeout the hygiene of a person.The abnormal nail may be congenital or due to some diseases.The cause for changes in the nail extend from simple reasons to life threatening diseases.Hence the examination by a doctor is essential for diagnosis .Some abnormal findings with probable causes are discussed here for general awareness.
1) Hygiene:-
We can make out an unhygienic nail very easily .Deposition of dirt under the distal end of nail plate can make a chance for ingestion of pathogens while eating.If nail cutting is not done properly it can result in worm troubles in children.When the worms crawl in the anal orifice children will scratch which lodges the ova of worms under the nails and will be taken in while eating.Prominent nail can also complicate a skin disease by habitual scratching.Sharp nails in small kids cause small wounds when they do feet kicking or hand waving.
2) Colour of the nails:-
a) Nails become pale in anaemia.
b) Opaque white discolouration(leuconychia) is seen in chronic renal failure and nephrotic syndrome.
c) Whitening is also seen in hypoalbuminaemia as in cirrhosis and kidney disorders.
d) Drugs like sulpha group,anti malarial and antibiotics ect can produce discolouration in the nails.
e) Fungal infection causes black discolouration.
f) In pseudomonas infection nails become black or green.
g) Nail bed infarction occures in vasculitis especially in SLE and polyarteritis.
h) Red dots are seen in nails due to splinter haemorrhages in subacute bacterial endo carditis, rheumatoid arthritis, trauma, collagen vascular diseases.
i) Blunt injury produces haemorrhage and causes blue/black discolouration.
j) Nails become brown in kidney diseases and in decreased adrenal activity.
k) In wilsons disease blue colour in semicircle appears in the nail.
l) When the blood supply decreases nail become yellow .In jaundice and psoriasis also nail become yellowish.
m) In yellow nail syndrome all nails become yellowish with pleural effusion.
3) Shape of nails:-
a) Clubbing: Here tissues at the base of nails are thickened and the angle between the nail base and the skin is obliterated. The nail becomes more convex and the finger tip becomes bulbous and looks like an end of a drumstick. When the condition becomes worse the nail looks like a parrot beak.
Causes of clubbing:-
Congenital Injuries
Severe chronic cyanosis
Lung diseases like empyema,bronchiactesis,carcinoma of bronchus and pulmonary tuberculosis.
Abdominal diseases like crohn's disease,polyposis of colon,ulcerative colitis,liver cirrhosis ect...
Heart diseases like fallot's tetralogy,subacute bacterial endocarditis and ect..
b) Koilonychia:-
Here the nails become concave like a spoon.This condition is seen in iron deficiency anaemia.In this condition the nails become thin,soft and brittle.The normal convexity will be replaced by concavity.
c) Longitudinal ridging is seen in raynaud's disease.
d) Cuticle becomes ragged in dermatomyositis.
e) Nail fold telangiectasia is a sign in dermatomyositis ,systemic sclerosis and SLE.
4) Structure and consistancy:-
a) Fungal infection of nail causes discolouration,deformity,hypertrophy and abnormal brittleness.
b) Thimble pitting of nail is charecteristic of psoriasis ,acute eczema and alopecia aereata.
c) The inflamation of cuticle or nail fold is called paronychia.
d) Onycholysis is the seperation of nail bed seen in psoriasis,infection and after taking tetracyclines.
e) Destruction of nail is seen in lichen planus,epidermolysis bullosa.
f) Missing nail is seen in nail patella syndrome.It is a hereditary disease.
g) Nails become brittle in raynauds disease and gangrene.
h) Falling of nail is seen in fungal infection,psoriasis and thyroid diseases.
5) Growth:-
Reduction in blood supply affects the growth of nails. Nail growth is also affected in severe ilness. when the disease disappears the growth starts again resulting in formation of transverse ridges.These lines are called Beau's lines and are healpful to date the onset of illness.
EFFECT OF ALCOHOL ON THE MEMBRANES.
EFFECT OF ALCOHOL ON THE MEMBRANES.
The parts which first suffer from alcohol are those expansions of the body which the anatomists call the membranes. "The skin is a membranous envelope. Through the whole of the alimentary surface, from the lips downward, and through the bronchial passages to their minutest ramifications, extends the mucous membrane. The lungs, the heart, the liver, the kidneys are folded in delicate membranes, which can be stripped easily from these parts. If you take a portion of bone, you will find it easy to strip off from it a membranous sheath or covering; if you examine a joint, you will find both the head and the socket lined with membranes. The whole of the intestines are enveloped in a fine membrane called peritoneum . All the muscles are enveloped in membranes, and the fasciculi, or bundles and fibres of muscles, have their membranous sheathing. The brain and spinal cord are enveloped in three membranes; one nearest to themselves, a pure vascular structure, a network of blood-vessels; another, a thin serous structure; a third, a strong fibrous structure. The eyeball is a structure of colloidal humors and membranes, and of nothing else. To complete the description, the minute structures of the vital organs are enrolled in membranous matter."
These membranes are the filters of the body. "In their absence there could be no building of structure, no solidification of tissue, nor organic mechanism. Passive themselves, they, nevertheless, separate all structures into their respective positions and adaptations."
Membranous deteriorations.
-------------------------
In order to make perfectly clear to your mind the action and use of these membranous expansions, and the way in which alcohol deteriorates them, and obstructs their work, we quote again from Dr. Richardson:
"The animal receives from the vegetable world and from the earth the food and drink it requires for its sustenance and motion. It receives colloidal food for its muscles: combustible food for its motion; water for the solution of its various parts; salt for constructive and other physical purposes. These have all to be arranged in the body; and they are arranged by means of the membranous envelopes. Through these membranes nothing can pass that is not, for the time, in a state of aqueous solution, like water or soluble salts. Water passes freely through them, salts pass freely through them, but the constructive matter of the active parts that is colloidal does not pass; it is retained in them until it is chemically decomposed into the soluble type of matter. When we take for our food a portion of animal flesh, it is first resolved, in digestion, into a soluble fluid before it can be absorbed; in the blood it is resolved into the fluid colloidal condition; in the solids it is laid down within the membranes into new structure, and when it has played its part, it is digested again, if I may so say, into a crystalloidal soluble substance, ready to be carried away and replaced by addition of new matter, then it is dialysed or passed through, the membranes into the blood, and is disposed of in the excretions.
"See, then, what an all-important part these membranous structures play in the animal life. Upon their integrity all the silent work of the building up of the body depends. If these membranes are rendered too porous, and let out the colloidal fluids of the blood the albumen, for example the body so circumstanced, dies; dies as if it were slowly bled to death. If, on the contrary, they become condensed or thickened, or loaded with foreign material, then they fail to allow the natural fluids to pass through them. They fail to dialyse, and the result is, either an accumulation of the fluid in a closed cavity, or contraction of the substance inclosed within the membrane, or dryness of membrane in surfaces that ought to be freely lubricated and kept apart. In old age we see the effects of modification of membrane naturally induced; we see the fixed joint, the shrunken and feeble muscle, the dimmed eye, the deaf ear, the enfeebled nervous function.
"It may possibly seem, at first sight, that I am leading immediately away from the subject of the secondary action of alcohol. It is not so. I am leading directly to it. Upon all these membranous structures alcohol exerts a direct perversion of action. It produces in them a thickening, a shrinking and an inactivity that reduces their functional power. That they may work rapidly and equally, they require to be at all times charged with water to saturation. If, into contact with them, any agent is brought that deprives them of water, then is their work interfered with; they cease to separate the saline constituents properly; and, if the evil that is thus started, be allowed to continue, they contract upon their contained matter in whatever organ it may be situated, and condense it.
"In brief, under the prolonged influence of alcohol those changes which take place from it in the blood corpuscles, extend to the other organic parts, involving them in structural deteriorations, which are always dangerous, and are often ultimately fatal."
The parts which first suffer from alcohol are those expansions of the body which the anatomists call the membranes. "The skin is a membranous envelope. Through the whole of the alimentary surface, from the lips downward, and through the bronchial passages to their minutest ramifications, extends the mucous membrane. The lungs, the heart, the liver, the kidneys are folded in delicate membranes, which can be stripped easily from these parts. If you take a portion of bone, you will find it easy to strip off from it a membranous sheath or covering; if you examine a joint, you will find both the head and the socket lined with membranes. The whole of the intestines are enveloped in a fine membrane called peritoneum . All the muscles are enveloped in membranes, and the fasciculi, or bundles and fibres of muscles, have their membranous sheathing. The brain and spinal cord are enveloped in three membranes; one nearest to themselves, a pure vascular structure, a network of blood-vessels; another, a thin serous structure; a third, a strong fibrous structure. The eyeball is a structure of colloidal humors and membranes, and of nothing else. To complete the description, the minute structures of the vital organs are enrolled in membranous matter."
These membranes are the filters of the body. "In their absence there could be no building of structure, no solidification of tissue, nor organic mechanism. Passive themselves, they, nevertheless, separate all structures into their respective positions and adaptations."
Membranous deteriorations.
-------------------------
In order to make perfectly clear to your mind the action and use of these membranous expansions, and the way in which alcohol deteriorates them, and obstructs their work, we quote again from Dr. Richardson:
"The animal receives from the vegetable world and from the earth the food and drink it requires for its sustenance and motion. It receives colloidal food for its muscles: combustible food for its motion; water for the solution of its various parts; salt for constructive and other physical purposes. These have all to be arranged in the body; and they are arranged by means of the membranous envelopes. Through these membranes nothing can pass that is not, for the time, in a state of aqueous solution, like water or soluble salts. Water passes freely through them, salts pass freely through them, but the constructive matter of the active parts that is colloidal does not pass; it is retained in them until it is chemically decomposed into the soluble type of matter. When we take for our food a portion of animal flesh, it is first resolved, in digestion, into a soluble fluid before it can be absorbed; in the blood it is resolved into the fluid colloidal condition; in the solids it is laid down within the membranes into new structure, and when it has played its part, it is digested again, if I may so say, into a crystalloidal soluble substance, ready to be carried away and replaced by addition of new matter, then it is dialysed or passed through, the membranes into the blood, and is disposed of in the excretions.
"See, then, what an all-important part these membranous structures play in the animal life. Upon their integrity all the silent work of the building up of the body depends. If these membranes are rendered too porous, and let out the colloidal fluids of the blood the albumen, for example the body so circumstanced, dies; dies as if it were slowly bled to death. If, on the contrary, they become condensed or thickened, or loaded with foreign material, then they fail to allow the natural fluids to pass through them. They fail to dialyse, and the result is, either an accumulation of the fluid in a closed cavity, or contraction of the substance inclosed within the membrane, or dryness of membrane in surfaces that ought to be freely lubricated and kept apart. In old age we see the effects of modification of membrane naturally induced; we see the fixed joint, the shrunken and feeble muscle, the dimmed eye, the deaf ear, the enfeebled nervous function.
"It may possibly seem, at first sight, that I am leading immediately away from the subject of the secondary action of alcohol. It is not so. I am leading directly to it. Upon all these membranous structures alcohol exerts a direct perversion of action. It produces in them a thickening, a shrinking and an inactivity that reduces their functional power. That they may work rapidly and equally, they require to be at all times charged with water to saturation. If, into contact with them, any agent is brought that deprives them of water, then is their work interfered with; they cease to separate the saline constituents properly; and, if the evil that is thus started, be allowed to continue, they contract upon their contained matter in whatever organ it may be situated, and condense it.
"In brief, under the prolonged influence of alcohol those changes which take place from it in the blood corpuscles, extend to the other organic parts, involving them in structural deteriorations, which are always dangerous, and are often ultimately fatal."
CEREBRAL PALSY
CEREBRAL PALSY
It is a non progressive neuromuscular disorder causing mild to severe disabilities throughout life.This condition is manifested as a group of persisting qualitative motor disorders which appear in young children due to damage to the brain during delivery or due to some pathological conditions in the intrauterine life.The neuroligical problems are multiple but non progressive in nature.Approximately 2 per 100 live birth is having this problem.This disease is having no hereditary tendency.
Causes of cerebral palsy:
1) Injury to the brain during delivery.
2) As a complication of forceps delivery.
3) Lack of oxygen supply to the baby during delivery.
4) Infections during delivery.
Signs and symptoms of cerebral palsy:--
The signs and symptoms may not be similar in all babies affected.Depending upon the damage to the brain there may be mild to severe lesions.
Mild cases:- 20% children will have mild disability.
Moderate cases:-50% cases are having moderate disability.The affected children require self help for assisting their impaired ambulation capacity.
Severe cases:-About 30% of the affected children are totally incapacited and bedridden and they allways need care from others.
Abnormal findings in cerebral palsy:-
1,Abnormal neonatal reflexes.
2,Stiffness of all muscles with awkward motion.
3,Extention of extremities on vertical suspension of the infant.
4,Scissoring of the lower limbs due to spasm of the adductor muscles of the thigh.
5,In severe cases the back bend backwards like and arch.
6,May have total or partial paralysis.
7,Arrest of neurological and behavioral developement.
8,Swallowing may be difficult in some cases.
9,Drooling of saliva.
10,Mild to severe mental retardations.
11,Abnormal movements are seen in some cases.
12,Tremors with typical movements.
13,If cerebellum is affected there will be loss of muscle tone with difficulty in walking.
14,Complete or partial loss of hearing.
15,Speech may be affected.
16,Squint and other visual problems may be associated.
17,Convulsions may be seen in some children.
Cerebral palsy is diagnosed by detailed clinical examination and by eliminating other similar diseases like brain tumour, progressive atrophy ect.All investigations like CT scan,MRI and routine investigations are needed to ruleout other diseases.
Management of carebral palsy:--
General management:
This includes proper nutrition and personal care. Symptomatic medicines are needed to reduce convulsions and muscle stiffness. Diazepam can reduce spasticity and athetosis.
Dantrolene sodium helps to relax skeletal muscles.
Physiotherapy:
Here massage,exercise, hydrotherapy and ect are needed.Special training is given to train walking,swallowing and talking.The affected children are also trained to hold articles for routine activities.
Rehabilitation:
Moral and social support should be given to these children.They should be send to special schools where special training can be given by trained staff.Mentally retarded children need special training.Depending up on the disabitity special instruments and machines are given for locomotion and to assist their daytoday activities.
Occupational therapy:
This is given by occupational therapists.They train the disabled people to do some suitable works so that these people can have their own income.
It is a non progressive neuromuscular disorder causing mild to severe disabilities throughout life.This condition is manifested as a group of persisting qualitative motor disorders which appear in young children due to damage to the brain during delivery or due to some pathological conditions in the intrauterine life.The neuroligical problems are multiple but non progressive in nature.Approximately 2 per 100 live birth is having this problem.This disease is having no hereditary tendency.
Causes of cerebral palsy:
1) Injury to the brain during delivery.
2) As a complication of forceps delivery.
3) Lack of oxygen supply to the baby during delivery.
4) Infections during delivery.
Signs and symptoms of cerebral palsy:--
The signs and symptoms may not be similar in all babies affected.Depending upon the damage to the brain there may be mild to severe lesions.
Mild cases:- 20% children will have mild disability.
Moderate cases:-50% cases are having moderate disability.The affected children require self help for assisting their impaired ambulation capacity.
Severe cases:-About 30% of the affected children are totally incapacited and bedridden and they allways need care from others.
Abnormal findings in cerebral palsy:-
1,Abnormal neonatal reflexes.
2,Stiffness of all muscles with awkward motion.
3,Extention of extremities on vertical suspension of the infant.
4,Scissoring of the lower limbs due to spasm of the adductor muscles of the thigh.
5,In severe cases the back bend backwards like and arch.
6,May have total or partial paralysis.
7,Arrest of neurological and behavioral developement.
8,Swallowing may be difficult in some cases.
9,Drooling of saliva.
10,Mild to severe mental retardations.
11,Abnormal movements are seen in some cases.
12,Tremors with typical movements.
13,If cerebellum is affected there will be loss of muscle tone with difficulty in walking.
14,Complete or partial loss of hearing.
15,Speech may be affected.
16,Squint and other visual problems may be associated.
17,Convulsions may be seen in some children.
Cerebral palsy is diagnosed by detailed clinical examination and by eliminating other similar diseases like brain tumour, progressive atrophy ect.All investigations like CT scan,MRI and routine investigations are needed to ruleout other diseases.
Management of carebral palsy:--
General management:
This includes proper nutrition and personal care. Symptomatic medicines are needed to reduce convulsions and muscle stiffness. Diazepam can reduce spasticity and athetosis.
Dantrolene sodium helps to relax skeletal muscles.
Physiotherapy:
Here massage,exercise, hydrotherapy and ect are needed.Special training is given to train walking,swallowing and talking.The affected children are also trained to hold articles for routine activities.
Rehabilitation:
Moral and social support should be given to these children.They should be send to special schools where special training can be given by trained staff.Mentally retarded children need special training.Depending up on the disabitity special instruments and machines are given for locomotion and to assist their daytoday activities.
Occupational therapy:
This is given by occupational therapists.They train the disabled people to do some suitable works so that these people can have their own income.
BAD BREATH
BAD BREATH
Causes of bad breath ?
Bad breath is a common health problem which greately affects the daytoday activities of somany people. The offenssive odor from the mouth is unpleasent to those who come in close contact with bad breathers. The problem will be doubled by psychological trauma leading to depression. The sufferers from this problem wil be isolated from the society. This can even lead to marital disharmony.
Literally speaking all humanbeings are badbreathres. Oral cavity contains millions of anaerobic bacteria like fusobacterium and actinomyces which acts on the protein of food materials and putrifies them. This process results in the formation of offenssive gases like hydrogen sulphide,methyl mescaptan,cadaverin,skatol,putrescine ect causing bad odor. If oral hygiene is not maintained properly all will suffer from bad breath. Most of us control this by regular brushing,tongue cleaning and gargling. Even after maintining cleanliness in the mouth some individuals suffer from offenssive smell due to various causes which has to be diagnosed and treated properly.
Some common causes of bad breath.
1) Poor oral hygiene:
If oral hygiene is not maintained properly the mouth becomes the seat for millions of bacteria which produce offenssive gases by degrading the food debris. Bad breath is severe in those who do not brush their teeth regularly and clean their mouth after every food. Snacks taken inbetween meals can also produce bad breath because of improper cleaning.
Badbreath is common in almost all people in the morning on waking. During sleep there is less production of saliva .Saliva has got some antibacterial properties which help to keep the mouth clean. Saliva conains oxygen molecules which is needed to make oral cavity aerobic. So the reduction in it's quantity during sleep makes a favourable condition for anaerobic bacteria.
2) Food habits:
The main cause of bad smell is due to degradation of protein by the bacteria and hence all food products rich in protein favours bad breath. Meat,fish,milk products, eggs,cakes,nuts,pear and ect can cause bad breath. Some food articles can produce particular type of smell which may be unpleasent. Raw onion can produce typical bad smell. It is said that an apple a day keeps the doctor away,a raw onion a day keeps everybody away. Eating groundnuts can also produce bad smell. However if proper cleaning is done smell can be reduced irrespective of the nature of food. Irregularity in timing of food can also produce bad breath. Small food articles taken in between the meals can also produce bad smell.
3) Biofilm:
There is formation of a thin sticky coating called biofilm on the tongue and oral mucosa. This coating is thick on the posterior aspect of the tongue where millions of gram negative bacteriae are seen .The thick coating on the tongue is always associated with badbreath. Even a thin biofilm can make anaerobic condition favourable for bacterial proliferation.
4) Dental caries:
This is a destructive process causing decalcification with distruction of enamel and dentine resulting in cavitisation of the tooth. These are produced mainly by the lactobacilli . Food particles are deposited inside these cavities and are putrified by the anaerobic bacteria producing bad smell. Normal brushing will not remove the food debris easily and hence they are putrified completely. Caries are common in schoolgoing children and in those who donot maintain proper oral hygiene .Calcium and vitamin deficiency can also predispose caries.
5) Gingivitis:
Gum is a mucus membrane with supporting connective tissue covering the tooth bearing borders of the jaw .The main function of gum is protection .Gingivitis is the inflammation of the gum .Due to various causes gum tissue get infected resulting in swelling,pain and discharge. If the condition become worse the infection spread towards peridontal area leading to continuous discharge called pyorrhoea. Some times the infection goes deep producing alveolar abscess with discharge of pus. Infection can even reach the bone causing osteomyelitis.All these conditions can produce offenssive smell.
6) Gum retraction:
When the gums retract from the teeth a gap is developed which will lodge food particles and cause bad breath.
7) Dental plaques and tartar deposits; Plaques and tartar is deposited mainly in the gaps between the teeth and gum. This will provide shelter for the food debris and bacteria causing bad breath.
8) Ulcerative lesions& coatings:
Almost all ulcerative lesions of the mouth are associated with bad breath. These lesions may be caused by bacteria,viruses,food allergies or due to autoimmune disorders. Apthous ulcer is the commonest amoung ulcerative lesions. Others are herpes,fungal infections,vincents angina,infectious mononucleosis,scarlet fever,diphtheria,drug reactions and ect. Cancerous ulcers produce severe bad breath. All fungal infections produce white coating(candidiasis). Leucoplakia is a white thick patch on the mucus membrane of the mouth & tongue. It is considered as a precancerous condition. Offenssive breath is associated with these conditions.
9) Diseases of the salivary glands:
Saliva is very useful to supply oxygen to all parts of the oral cavity. Even a thin film of coating called biofilm can provide an anaerobic condition in the mouth. Saliva can wet these layers and make an aerobic condition which is unfavourable for the bacteria .Any condition which reduces the production of saliva can increase bacterial activity. Some times the salivary duct is obstructed by stones or tumors.Cancer of the salivary gland is associated with offenssive odor. In suppurative parotitis purulant dischrge in to the mouth causes bad breath.
10) Tonsillitis:
Tonsils are a pair of lymphoid tissue situated in the lateral wall of oropharynx. Inflammation of the tonsil is called tonsillitis. Bad breath is seen in both acute and chronic tonsillitis. Quinsy or peritonsillar abscess can also produce bad breath.
11) Tonsillar plaques & tonsillar fluid:
If bad breath persists even after maintaining proper oral hygeine there is possibility of this condition. Serous fluid secreated from the folds of tonsil is very offenssive. Some patients complain that they hawk some cheesy materials from the throat;which are very offenssive in nature. These are formed inside the tonsillar crypts which contain thousands of bacteriae. In such conditions tonsillectomy gives noticiable relief from bad breath.
12) Pharyngitis& pharyngial abscess:
Pharynx is a fibromuscular tube which forms the upper part of the digestive & respiratory tract. Inflmmation of the pharynx is called pharyngitis, caused mainly by bacteria and viruses. Bad breath is present in pharyngitis along with other signs like cough and throat irritation. Abscesses in the wall of pharynx can also produce offenssive discharge of pus in to the throat.
13) Dentures:
Denture users may complain about bad smell due to lodgement of small food debris in between. Proper brushing may not be possible in denture users especially fixed dentures.
14) Tobacco:
Tobacco chewing is associated with bad breath. The smell of tobacco itself is unpleasent for others. Tobacco can irritate the mucus membrane and cause ulcers and coatings. Gingivitis and pyorrhoea are common in tobacco chewers. Tartar is deposited on the teeth mainly near the gums. Tobacco chewers get gastric acidity with eructations. All these causes offenssive smell.
15) Smoking:
Smokers always have bad smell. It can also produce lesions in the mouth & lungs causing bad breath.Smoking increases carbon dioxide in the oral cavity & reduces oxygen level,causing a favourable condition for bacteria. Smoking reduses appetite & thirst hence acid peptic disease is common in chain smokers.
16) Lesions in the nose & ear:
Bad breath is occasionally seen in sinusitis(infection of para nasal sinuses). In case of post nasal dripping bad breath is common due to the presence of protein in the discharges. These proteins are degraded by the bacteria. Infection in the middle ear with discharge of pus in to the throat through the eustachian tube(passage from middle ear to the throat)can also cause offenssive odor. Chronic rhinitis(infection of mucus membrane of nose) and forign bodies in the nose can also produce bad smell in the expired air.
17) Diabetes mellitus:
Mostly all diabetic patients suffer from bad breath. Coated tongue,ulcers &coatings in the mouth ,increased sugar level in tissues ect are responsible for bad breath.Bacterial growth in diabetic patient is very faster than non diabetic individuals.
18) Fevers:
Bad breath is common in almost all fevers. Even an acute fever can produce bad breath. Severe bad breath is seen in typhoid .Other infectious diseases like Tuberculosis , AIDS ect produce bad smell.
19) Fasting & dehydration:
Dry mouth favours bacterial activity. So any condition which produce dryness in the mouth makes the breath offenssive. Eventhough the food particles are known to produce bad breath, fasting can also produce the same. Production of saliva is also reduced during fasting. Chewing and swallowing also helps to keep the mouth clean.
20) Bedridden patients:
Bedridden patients suffer from offenssive breath due to thick coating on the tongue. water intake is also limited in these patients. Regurgitation of food aggravates the condition. Since they talk less aeration in the oral cavity is reduced which favours anaerobic bacteria to become active.
21) Diseases of stomach & esophagus:
Eructation of gas and food produce unpleasent smell. Abnormality in the function of lower sphincter can allow the food to regurgitate upwards causing bad breath. Bad breath is also common in gastritis,gastric ulcer and cancer of stomach.
22) Intestinal diseases:
Bad breath is common in patients suffering from ulcerative lesions of intestine like ulcerative collitis..Other diseases are malabsorption syndrome intestinal tuberculosis, peritonitis ect.
23) Diseases of lungs:
Lung diseases like pneumonia, lung abscess,chronic bronchitis,bronchiectasis,tuberculosis, lung cancer ect can produce bad odor during expiration.
24) Liver disorders:
Liver diseases like hepatitis, cirrhosis,can cause bad breath.Gall bladder diseases with vomiting also causes unpleasent odor.
25) Psychiatric patients:
Bad breath is common in psychotic patients due to poor hygiene,irregular food habits,less water intake and ect.
26) Somatisation disorder:
This is a psychiatric disorder charecterised by the presence of a physical symptom that suggest a medical illness .These patients come with physical complaints like pain,nausea difficult respiration, bad smell ect. This condition is diagnosed after detailed examination of the patient with all investigations.Since this is a psychiatric disorder it has to be managed with a psychological approach.
[ THE POINTS MENTIONED IN THIS ARTICLE IS FOR GENERAL INFORMATION. ANY PERSON HAVING BAD BREATH SHOULD CONSULT A QUALIFIED DOCTOR ]
Causes of bad breath ?
Bad breath is a common health problem which greately affects the daytoday activities of somany people. The offenssive odor from the mouth is unpleasent to those who come in close contact with bad breathers. The problem will be doubled by psychological trauma leading to depression. The sufferers from this problem wil be isolated from the society. This can even lead to marital disharmony.
Literally speaking all humanbeings are badbreathres. Oral cavity contains millions of anaerobic bacteria like fusobacterium and actinomyces which acts on the protein of food materials and putrifies them. This process results in the formation of offenssive gases like hydrogen sulphide,methyl mescaptan,cadaverin,skatol,putrescine ect causing bad odor. If oral hygiene is not maintained properly all will suffer from bad breath. Most of us control this by regular brushing,tongue cleaning and gargling. Even after maintining cleanliness in the mouth some individuals suffer from offenssive smell due to various causes which has to be diagnosed and treated properly.
Some common causes of bad breath.
1) Poor oral hygiene:
If oral hygiene is not maintained properly the mouth becomes the seat for millions of bacteria which produce offenssive gases by degrading the food debris. Bad breath is severe in those who do not brush their teeth regularly and clean their mouth after every food. Snacks taken inbetween meals can also produce bad breath because of improper cleaning.
Badbreath is common in almost all people in the morning on waking. During sleep there is less production of saliva .Saliva has got some antibacterial properties which help to keep the mouth clean. Saliva conains oxygen molecules which is needed to make oral cavity aerobic. So the reduction in it's quantity during sleep makes a favourable condition for anaerobic bacteria.
2) Food habits:
The main cause of bad smell is due to degradation of protein by the bacteria and hence all food products rich in protein favours bad breath. Meat,fish,milk products, eggs,cakes,nuts,pear and ect can cause bad breath. Some food articles can produce particular type of smell which may be unpleasent. Raw onion can produce typical bad smell. It is said that an apple a day keeps the doctor away,a raw onion a day keeps everybody away. Eating groundnuts can also produce bad smell. However if proper cleaning is done smell can be reduced irrespective of the nature of food. Irregularity in timing of food can also produce bad breath. Small food articles taken in between the meals can also produce bad smell.
3) Biofilm:
There is formation of a thin sticky coating called biofilm on the tongue and oral mucosa. This coating is thick on the posterior aspect of the tongue where millions of gram negative bacteriae are seen .The thick coating on the tongue is always associated with badbreath. Even a thin biofilm can make anaerobic condition favourable for bacterial proliferation.
4) Dental caries:
This is a destructive process causing decalcification with distruction of enamel and dentine resulting in cavitisation of the tooth. These are produced mainly by the lactobacilli . Food particles are deposited inside these cavities and are putrified by the anaerobic bacteria producing bad smell. Normal brushing will not remove the food debris easily and hence they are putrified completely. Caries are common in schoolgoing children and in those who donot maintain proper oral hygiene .Calcium and vitamin deficiency can also predispose caries.
5) Gingivitis:
Gum is a mucus membrane with supporting connective tissue covering the tooth bearing borders of the jaw .The main function of gum is protection .Gingivitis is the inflammation of the gum .Due to various causes gum tissue get infected resulting in swelling,pain and discharge. If the condition become worse the infection spread towards peridontal area leading to continuous discharge called pyorrhoea. Some times the infection goes deep producing alveolar abscess with discharge of pus. Infection can even reach the bone causing osteomyelitis.All these conditions can produce offenssive smell.
6) Gum retraction:
When the gums retract from the teeth a gap is developed which will lodge food particles and cause bad breath.
7) Dental plaques and tartar deposits; Plaques and tartar is deposited mainly in the gaps between the teeth and gum. This will provide shelter for the food debris and bacteria causing bad breath.
8) Ulcerative lesions& coatings:
Almost all ulcerative lesions of the mouth are associated with bad breath. These lesions may be caused by bacteria,viruses,food allergies or due to autoimmune disorders. Apthous ulcer is the commonest amoung ulcerative lesions. Others are herpes,fungal infections,vincents angina,infectious mononucleosis,scarlet fever,diphtheria,drug reactions and ect. Cancerous ulcers produce severe bad breath. All fungal infections produce white coating(candidiasis). Leucoplakia is a white thick patch on the mucus membrane of the mouth & tongue. It is considered as a precancerous condition. Offenssive breath is associated with these conditions.
9) Diseases of the salivary glands:
Saliva is very useful to supply oxygen to all parts of the oral cavity. Even a thin film of coating called biofilm can provide an anaerobic condition in the mouth. Saliva can wet these layers and make an aerobic condition which is unfavourable for the bacteria .Any condition which reduces the production of saliva can increase bacterial activity. Some times the salivary duct is obstructed by stones or tumors.Cancer of the salivary gland is associated with offenssive odor. In suppurative parotitis purulant dischrge in to the mouth causes bad breath.
10) Tonsillitis:
Tonsils are a pair of lymphoid tissue situated in the lateral wall of oropharynx. Inflammation of the tonsil is called tonsillitis. Bad breath is seen in both acute and chronic tonsillitis. Quinsy or peritonsillar abscess can also produce bad breath.
11) Tonsillar plaques & tonsillar fluid:
If bad breath persists even after maintaining proper oral hygeine there is possibility of this condition. Serous fluid secreated from the folds of tonsil is very offenssive. Some patients complain that they hawk some cheesy materials from the throat;which are very offenssive in nature. These are formed inside the tonsillar crypts which contain thousands of bacteriae. In such conditions tonsillectomy gives noticiable relief from bad breath.
12) Pharyngitis& pharyngial abscess:
Pharynx is a fibromuscular tube which forms the upper part of the digestive & respiratory tract. Inflmmation of the pharynx is called pharyngitis, caused mainly by bacteria and viruses. Bad breath is present in pharyngitis along with other signs like cough and throat irritation. Abscesses in the wall of pharynx can also produce offenssive discharge of pus in to the throat.
13) Dentures:
Denture users may complain about bad smell due to lodgement of small food debris in between. Proper brushing may not be possible in denture users especially fixed dentures.
14) Tobacco:
Tobacco chewing is associated with bad breath. The smell of tobacco itself is unpleasent for others. Tobacco can irritate the mucus membrane and cause ulcers and coatings. Gingivitis and pyorrhoea are common in tobacco chewers. Tartar is deposited on the teeth mainly near the gums. Tobacco chewers get gastric acidity with eructations. All these causes offenssive smell.
15) Smoking:
Smokers always have bad smell. It can also produce lesions in the mouth & lungs causing bad breath.Smoking increases carbon dioxide in the oral cavity & reduces oxygen level,causing a favourable condition for bacteria. Smoking reduses appetite & thirst hence acid peptic disease is common in chain smokers.
16) Lesions in the nose & ear:
Bad breath is occasionally seen in sinusitis(infection of para nasal sinuses). In case of post nasal dripping bad breath is common due to the presence of protein in the discharges. These proteins are degraded by the bacteria. Infection in the middle ear with discharge of pus in to the throat through the eustachian tube(passage from middle ear to the throat)can also cause offenssive odor. Chronic rhinitis(infection of mucus membrane of nose) and forign bodies in the nose can also produce bad smell in the expired air.
17) Diabetes mellitus:
Mostly all diabetic patients suffer from bad breath. Coated tongue,ulcers &coatings in the mouth ,increased sugar level in tissues ect are responsible for bad breath.Bacterial growth in diabetic patient is very faster than non diabetic individuals.
18) Fevers:
Bad breath is common in almost all fevers. Even an acute fever can produce bad breath. Severe bad breath is seen in typhoid .Other infectious diseases like Tuberculosis , AIDS ect produce bad smell.
19) Fasting & dehydration:
Dry mouth favours bacterial activity. So any condition which produce dryness in the mouth makes the breath offenssive. Eventhough the food particles are known to produce bad breath, fasting can also produce the same. Production of saliva is also reduced during fasting. Chewing and swallowing also helps to keep the mouth clean.
20) Bedridden patients:
Bedridden patients suffer from offenssive breath due to thick coating on the tongue. water intake is also limited in these patients. Regurgitation of food aggravates the condition. Since they talk less aeration in the oral cavity is reduced which favours anaerobic bacteria to become active.
21) Diseases of stomach & esophagus:
Eructation of gas and food produce unpleasent smell. Abnormality in the function of lower sphincter can allow the food to regurgitate upwards causing bad breath. Bad breath is also common in gastritis,gastric ulcer and cancer of stomach.
22) Intestinal diseases:
Bad breath is common in patients suffering from ulcerative lesions of intestine like ulcerative collitis..Other diseases are malabsorption syndrome intestinal tuberculosis, peritonitis ect.
23) Diseases of lungs:
Lung diseases like pneumonia, lung abscess,chronic bronchitis,bronchiectasis,tuberculosis, lung cancer ect can produce bad odor during expiration.
24) Liver disorders:
Liver diseases like hepatitis, cirrhosis,can cause bad breath.Gall bladder diseases with vomiting also causes unpleasent odor.
25) Psychiatric patients:
Bad breath is common in psychotic patients due to poor hygiene,irregular food habits,less water intake and ect.
26) Somatisation disorder:
This is a psychiatric disorder charecterised by the presence of a physical symptom that suggest a medical illness .These patients come with physical complaints like pain,nausea difficult respiration, bad smell ect. This condition is diagnosed after detailed examination of the patient with all investigations.Since this is a psychiatric disorder it has to be managed with a psychological approach.
[ THE POINTS MENTIONED IN THIS ARTICLE IS FOR GENERAL INFORMATION. ANY PERSON HAVING BAD BREATH SHOULD CONSULT A QUALIFIED DOCTOR ]
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