By A. Folleck. Syracuse University.

For this reason discount 500 mg mildronate, thymus-therapy has joined the great family of Faustian therapies — with cellulo-therapy mildronate 500mg with visa, the Aslan cures, and Niacin as recommended by the Church of Scientology. They all have one major therapeutic point in common: they are targeted to subjects who are dis- abled, but who have enough money to pay for the sessions recom- mended by people writing prescriptions, people who are rather more interested in their patients’ wallets than in their health. NEEDLES AND PAINS All I want is to learn five or six big words of medicine to enhance my speech and to give me the airs of an intelligent man. Patients who are keen to be taken care of like acupuncture even more than homeopathy. Indeed, acupuncture meets many of the crite- ria of fascination that are lacking in official medicine. First of all, this is a form of therapy that comes from a remote and exotic country, China, and is laden with the wisdom of two millennia. Regarded as a soft medicine, acupuncture is easy to integrate into an esoteric program, such as that of the Tao. At the same time, it is founded on one of the most material practices, that of moxas (a plant substance, burned on the skin to cauterize it), or of needles, thus com- bining the physical and the psychic. Lastly, the acupuncture session creates a bond between the acupuncturist and the patient, both of whom become part of the same sacred magical rite; the acupuncture session becomes an initiatory experience. If there is any similarity between acupuncture as it was practiced long ago and the way it is practiced today, then acupuncture, and phyto-therapy, are certainly the oldest "alternative" medicines. The first known written reference to acupuncture is a comment in The Book th of Springs and Autumns, from the 6 century BC, with hints of earlier evi- 51 Healing or Stealing? The Yin era’s ideogram representing medicine was an emblem in the shape of an arrow. On that basis, several authors have hypothesized that there might be a relationship between the ideogram for medicine, certain rit- 1 ual magic, and the invention of acupuncture. According to Claire Sagnières, the ideogram for medicine was se- 2 lected because the sorcerers (shamans) used arrows to kill demons. Many ethnological papers describe the ritual intended to drive away demons — to ward off storms, for example — using a volley of arrows. Voodoo rituals, in which a doll is pierced with needles, are based on the same logic. It is easy to make the leap from the field of symbolism to that of reality and to thrust arrows under the skin, in order to drive out the demons that are lodged in painful places. W hile lightning is represented in Classical W estern art by an arrow (lightning bolts in the hand of Zeus, for example), its visible result on earth is fire — divine fire, projected onto the ground. Chinese acu- puncture, since its creation, has relied on the use of fire through moxipuncture, or moxibustion. This consists in heating certain points of the body by holding red-hot sticks close to the skin’s surface or by using little cones of burning Artemisia moxa or other herbs, positioned over the skin. Cupping, which used to be a popular remedy in many countries, follows the same logic (in cupping, blood is drawn to the skin’s surface by applying a cup, mouth down, to the area and creating a vacuum inside it); this technique was used at various strategic points of the body. These practices make frequent reference to fire, and it is probably only the fact that needles are easier to use that led to their becoming more common than moxas. For some 20 centuries, moxibustion, acupuncture and a related practice in which a mallet, known as "the apple blossom", is used to 52 Needles and Pains stimulate points of the body, were common in China. These techniques th seem to have reached Europe only at the end of the 17 century, when they were introduced by Ten Rhyne, a doctor from the East Indies Company. They were slow in spreading, until they were revealed to the general public by the publication of the Precis of True Chinese Acupuncture, by Georges Soulié de Morant, French Consul in China, in about 1930. During the Second W orld W ar, these practices were more or less eclipsed; they returned to fashion in the 1960’s and really began making waves in the W est after that, buoyed along by the waves of interest in Hinduism, Chinese traditions, and the New Age that were so popular in those days. In China, however, acupuncture has not always been so successful as we sometimes think. In 1882, the Chinese emperor published an edict prohibiting acupuncture, under the pretext that it was an impedi- ment to medical progress. Acupuncture was reintroduced only after Mao Zedong came to power, and its justification then was purely eco- nomic: this cheap technique helped make up for the lack of drugs. So today, in China, people may still resort to acupuncture, but its impor- tance is diminishing day by day and it seems to be increasingly an ex- port product. The principles of acupuncture are entirely based on the notion that an individual’s vital energy is conveyed throughout the whole body, via special paths called meridian lines. These meridian lines are supposedly accessible from certain points in the skin: the acupuncture points. In these doctrines, all the elements that make up the world are characterized by a balance (or an imbalance) between the two generating principles of the uni- verse, the yin and the yang.

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When the assessment of volume status by diet and exercise therapy buy generic mildronate 250mg on-line, no special preoperative becomes critically important buy cheap mildronate 250mg on line, it is often necessary to preparation is required. Hyperglycemia can be effec- measure pulmonary capillary wedge pressure using a tively treated with supplemental short-acting insulin Swan–Ganz catheter. The patients receiv- Intravenous fluid administration must be adjusted ing oral hypoglycemic medications should have these for the older surgical patient because there is a decline held on the day of the operation. Hyperglycemia can be in both total body water and intracellular water with treated with short-acting insulin. For men between 65 and 85 years of age insulin, several management regimens are possible. More commonly, for lular volume is approximately 20% to 25% of body patients normally treated with a single dose of insulin weight. In the absence of acute stress and conditions each day, one-half to two-thirds of the usual dose of known to affect salt and water balance, the daily meta- insulin is given on the morning of surgery, and a glucose- bolic requirements per liter of intracellular fluid are as containing intravenous solution is administered at a rate follows: of 5 to 10 g glucose per hour. For patients who are normally managed with multiple Water, 100 mL does of insulin throughout the day, one-third the usual Energy, 100 kcal morning dose is administered on the morning of sur- Protein, 3 g gery, and a glucose-containing solution is infused intra- Sodium, 3 mmol 89 venously. Blood sugar control is easier if a constant rate Potassium, 2 mmol of infusion of the glucose solution is maintained while For example, an 80-year-old woman weighing 40 kg has nonglucose-containing intravenous fluids are used to an estimated intracellular volume of 10 L. Additional nance requirements would be 1 L water, 1000 kcal, 30 g doses of regular insulin should be administered to control protein, 30 mmol sodium, and 20 mmol potassium. Fluid blood sugar levels; a 6-h interval between glucose meas- and electrolyte status must be closely monitored and urements is commonly used. In addition to meticulous adjusted according to the response of the patient and the attention to blood sugar levels, it is important to monitor development of other pathophysiologic conditions. Myocardial ischemia can be silent and Endocrine Disorders may be detected unexpectedly on postoperative electro- Diabetes mellitus, usually type II, is common among cardiograms. It has been estimated that of diabetic Thyroid disease is not as prevalent as diabetes but, if patients undergoing surgery, more than 75% are over the undetected, can result in major complications periopera- age of 50. The prevalence of hypothyroidism in hospitalized ment of surgical patients but also predisposes the patient older patients has been reported to be 9. With the stress and tissue injury of tain a high index of suspicion for thyroid illness in this surgery, there is an increase in many of the counterregu- population. The consequences of operating upon a latory hormones: cortisol, epinephrine, glucagon, and patient with unsuspected hypothyroidism can be signifi- growth hormone. These patients metabolize medications more slowly, esis, and the catecholamines can directly depress the and their increased sensitivity to central nervous system release of insulin from the pancreas and blunt insulin depressants can result in respiratory insufficiency. While the potential for these perioperative nutritional supplements: those who are complications should be suspected and preventive meas- severely malnourished before major surgery; and those ures instituted, hypothyroidism should not be considered who undergo operations resulting in prolonged periods an absolute contraindication to necessary operative of inadequate enteral intake. When to patients with a functioning gastrointestinal tract who hypothyroidism is severe, an intravenous dose of 300 to were malnourished preoperatively and who are unable to 500 mg l-thyroxine will significantly improve basal meta- consume adequate calories orally. Corticosteroids should also be given tion is indicated for malnourished patients who have a in the perioperative period because the acute rise in basal nonfunctioning gastrointestinal tract or for whom enteral metabolic rate can exhaust adrenal reserves. Older persons may be particu- Neuropsychiatric Disorders larly prone to iodine-induced hyperthyroidism from non- ionic contrast radiography. The prevalence of dementia ation is necessary, the patient can be treated with 1000 is about 5% among persons aged 65 years; it increases to mg propylthiouracil by mouth and a beta-blocker to about 25% in those 80 years of age and older. Sodium of older patients admitted for repair of hip fractures in iodide is often given to inhibit the release of thyroid Sweden reported a prevalence of dementia of 15%. Iodide Depression also is prevalent among older persons and can be given either by mouth or intravenously; adminis- can be exacerbated by any acute illness or hospitaliza- tration should be delayed until at least 1 h after the tion. Anesthesia and surgery can have profound effects propylthiouracil to allow time for the latter to block on mental functioning. Supplemental corticosteroids are also rec- with surgery along with the previously discussed effects ommended for hyperthyroid patients undergoing emer- on all the vital organ system can compromise cerebral gency operations. These supplements are given to protect function and exacerbate or precipitate neuropsychiatric against the possibility of adrenal insufficiency related to disorders. The physiologic and behavioral manifestations the chronic hyper-metabolic state and because corticos- of neuropsychiatric disorders can significantly complicate teroids may lower serum thyroxine and thyroid-stimulat- perioperative care and often lead to prolonged hospital ing hormone levels. The major manifestation of this condition is an alteration in consciousness, and it is, by Nutrition 99 definition, a transient disorder. One prospective study Surgery and wound healing cause increased energy reported delirium in 44% of older patients undergoing demands. In some malnourished or high- dure nor the type of anesthetic used (halothane versus risk patients, preoperative total parenteral nutrition has epidural) were predictors of an acute confusional state. Risk factors included age 70 years and parenteral nutrition should be reserved for those patients older; self-reported alcohol abuse; poor cognitive status; in whom the gastrointestinal tract cannot be used. A in commonly used nutritional indices are associated careful clinical assessment of the patient should focus with reduced perioperative morbidity; hence, the optimal on the possibility of infection, metabolic derangements, duration of nutritional support is unknown. Additional central nervous system events, myocardial ischemia, studies are needed in patients most likely to benefit from sensory deprivation, or drug intoxication.

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