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https://pharmacy.unc.edu/news/directory/drhoney/
It is proposed that: Clinical trial data should only be included if the data suggest a signal or are relevant to symptoms gastritis buy olanzapine 2.5 mg free shipping any suspected changes in the benefit-risk relationship for the product medicine ball slams buy generic olanzapine on-line. Currently medications are administered to buy discount olanzapine 10 mg on-line, line listings per se are not entered into the databases of any known regulator; furthermore symptoms zinc deficiency order 10mg olanzapine amex, review of extensive line listings on paper is highly impractical. If a company does not submit a line listing, it must provide one within 10 working days of a regulatory request. It must be emphasized that companies must still review and analyze all the case histories received in the time period to search for safety signals. When the line listing is omitted, presentation and analysis of the case reports through the summary tabulation(s) becomes especially im 2 Inprinciple,company-generatedlinelistingsmaybecomemootinthefutureforthoseregulatorsableand willing to receive individual case reports electronically, especially on an ongoing basis. However, it is uncertain when such a situation will prevail andfurthermoretherewillpresumablyalwaysbesomeauthoritiesrequiringthatlinelistingsbesubmitted. There is no magic number that qualifies as defining a very large, unwieldy volume for a line listing; 200 is chosen arbitrarily as a reasonable cut-off. Clearly, for any event involving a signal or key safety issue, all relevant cases should be line-listed independent of any cut-off number. However, care must be taken to ensure that medically important distinctions are not overlooked by using terms at too high a level. Also, it is important that when possible, diagnoses rather than (or in addition to) signs and symptoms be identified in summary tabulations. Presentation and assessment in terms of listedness (rather than by serious vs non-serious) under each system organ class may be the most meaningful approach. A large number of clinical or non-clinical studies may have been conducted during a five-year reporting period. Similarly, a comprehensive literature search for an active drug could potentially produce several hundred papers. The inclusion and discussion of literature reports should be selective and focus on publications relevant to safety findings, independent of listedness. The key question, of course, is how to define little or no new information or findings. The following criteria are suggested, all of which ought to be considered: (1) No serious unlisted cases have been received, there are very few serious listed cases. As usual, a list of any completed studies that focussed on safety should be mentioned. Therefore, it is incumbent on the company to use its judgment on whether local label alterations constitute ‘‘regulatory actions for safety reasons. While the example is for an annual report, the same format could be used for 6 month and 5 year reports as well. Please note that the example purposely does not technically satisfy all the suggested criteria but is included to illustrate how a special situation can be handled. Proposals Relating to Frequency and Timing of Reporting As already discussed, there are circumstances in which the usual reporting schedule as designated by many regulators does not or cannot readily apply. In order to avoid the need for a company to prepare a separate one-year report when the product is still under a 6-monthly reporting cycle, a need has been expressed by regulators for some other way to tie together (‘‘bridge’’) the two 6-month reports (thus, a Summary Bridging Report). One possible practical approach to help overcome the difficulty associated in general with timing and frequency of reporting for new drugs would be to continue with a six-monthly or annual schedule indefinitely, especially if new indications or formulations are likely to be introduced over the years. However, whether such an approach is suitable will depend on the number and types of products a company sells, business processes, resources, and other factors. For example, it may be used to cover four six-month reports in lieu of a separate two-year report, or five separate annual reports for a new, cumulative 5-year report, including reports for license renewal in Europe. The bridging report would obviously cross reference the covered individual reports and, although some of them may have been previously submitted as part of a shorter reporting cycle, the actual reports should be appended. The submission of a summary bridging report should not by itself indicate a need for a new review of the data. The summary bridging report itself, however, is not the tool for such interim (addendum) reporting. It may not be appropriate to structure this chronologically but according to issues and the most recent measures taken to manage them. Exposure data — an estimate of the total number of patients exposed in the time period covered by the bridging report (including from clinical trials if appropriate). Overall Safety Evaluation and Conclusion — mention only key unresolved issues and possible measures to address the problem. Until then, an expedient approach is needed to manage the inconsistencies in harmonization without adding an undue burden for both companies and regulators in the preparation and review of extra reports. They should not be required routinely but should be prepared only on special regulatory request. However, recognizing the limitations of pharmacovigilance resources, the Working Group proposes the following minimum information for inclusion in an addendum report. Line listing and/or summary tabulations — inclusion of the new cases in the usual format. If the volume of reports is high, as already re commended consideration should be given to excluding the line-listing. Conclusion — a brief overview of the new cases included and a comment on whether or not they are in line with the known safety profile of the product. In summary, the purpose of an addendum report is to supplement, not replace, the basic reporting cycle. Subsequent five-year license renewal reports would be submitted at five year intervals following the submission of the first ‘‘five year’’ report (that really covers, as stated, 4. It was agreed that it should be acceptable to provide multiples of six-monthly or annual reports that have already been prepared by the company to cover the period requested by individual regulatory authorities to comply with their own local requirements. However, it was considered necessary that the reports be accompanied by a document chronologically summarizing the information contained in the series of reports (a Summary Bridging Report as described above). This same concept is applicable for all five-year license renewals subsequent to the first one. Individual regulators may define what is meant by ‘‘old’’ products; there is no general definition. However, it must be recognized that such a conversion for existing drugs is time consuming, expensive and not very practical especially for global companies with extensive portfolios and line extensions; each attempt requires a variation application within each country. It is also necessary, as usual, to indicate which countries, if any, have refused approval or license renewal, or in which the product has been withdrawn for safety reasons, along with an explanation. It is also important to remember that discussion of serious unlisted cases should cover cumulative data. There are two general situations for which regulators must consider whether it is necessary to ask companies to revert to a six-month reporting interval when a longer period (one or five years. The need to reset the clock under any circumstances should be driven by the data available to support the product’s safety profile and the relative 159 stability of that profile, not by regulatory approval dates. The safety profile of a product is best characterized according to the number and types of patients treated; reporting frequency should be influenced by the extent of clinical knowledge of the product. For such products, it is recommended that regulators in the new market accept a summary tabulation (with or without supporting line listings) of spontaneously reported adverse events over the shorter periods in the new market (say every 6 months for a reasonable length of time, perhaps two years). For such short-interval data submissions, review of the worldwide literature is not considered necessary, especially for older products already available generically in major markets. For both (a) and (b), in any event, consideration for restarting the clock should be discussed between the regulators and the company preferably prior to but certainly no later than time of approval of the relevant application dossier. There is a need for a greater degree of flexibility in the time line to ensure that not only all the relevant safety data are covered (line listings, tabulations, literature, studies) but appropriate analysis and interpretation of the data are made (overall analysis and conclusions). However, for a recently introduced product with multiple safety issues that is indicated for a complicated disease syndrome and is associated with a high volume of adverse event reports, a longer preparation time. When a company realizes that 60 days may not suffice, it should alert regulators to a possible delay and provide an explanation; this will allow the regulators to facilitate their own review planning, especially if it involves multiple agencies. It would provide the reader, especially the regulators, with a description of the basic content and most important findings as a guide to the full document. Introduction Obtaining and understanding patient exposure information (the ‘‘denominator’’) is important for both manufacturers and regulatory authorities to help assess the benefits and risks of any medicinal product 1 and to place such information in proper perspective. The need to evaluate the benefit-risk relationship spans the continuum of a product’s lifecycle, from early in clinical development through its use in the marketplace. In general, appropriate use of denominator data is part of good epidemiological and public health practices. There are many difficulties associated with obtaining and using the relevant data, particularly from sources outside the relatively controlled environment of clinical trials or other studies in which the size and characteristics of the treated populations are known with considerable accuracy. Estimating person-use for marketed drugs usually relies on gross approximations, especially for non-prescription products, and represents more of an art than a science.
Roman Motherwort (Motherwort). Olanzapine.
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- Heart conditions (fast heart rate, abnormal rhythm), over-active thyroid (hyperthyroidism), itching, shingles, intestinal gas (flatulence), lack of menstrual periods, and other uses.
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Impression Cytology Impression cytology is a method by which goblet cell densities on the conjunctival surface can be counted medications not to take before surgery buy cheap olanzapine online. In normal persons medicine cabinets with lights order olanzapine with visa, the goblet cell population is highest in the infranasal quadrant symptoms 3dp5dt purchase olanzapine with a visa. Loss of goblet cells has been documented in trachoma treatment centers buy olanzapine 5mg, mucous membrane pemphigoid, Stevens-Johnson syndrome, and avitaminosis A. Fluorescein Staining Touching the conjunctiva with a dry strip of fluorescein is a good indicator of wetness, and the tear meniscus can be seen easily. Fluorescein will stain the eroded and denuded areas as well as microscopic defects of the corneal epithelium (Figure 5–16). Rose Bengal and Lissamine Green Staining Rose bengal (Figure 5–22) and lissamine green are equally sensitive for staining the conjunctiva. Both dyes will stain all desiccated nonvital epithelial cells of the conjunctiva and to a lesser extent the cornea. Tear Lysozyme Assay Reduction in tear lysozyme concentration usually occurs early in the course of Sjögren syndrome and is helpful in diagnosis. Tears can be collected on Schirmer strips and assayed, usually by spectrophotometric methods. Tear Osmolality 270 Hyperosmolality of tears has been documented in dry eye syndrome and in contact lens wearers and is thought to be a consequence of decreased corneal sensitivity. Reports claim that hyperosmolality is the most specific test for dry eye syndrome. Hyperosmolality may be found even when Schirmer test and staining with rose bengal and lissamine green are normal. Lactoferrin Tear lactoferrin is low in patients with hyposecretion of the lacrimal gland. Complications Early in the course of dry eye syndrome, vision is slightly impaired. In advanced cases, corneal ulceration, corneal thinning, and perforation may develop. Secondary bacterial infection occasionally occurs, and corneal scarring and vascularization may result in marked reduction in vision. Treatment the patient should understand that dry eye syndrome is a chronic condition and complete relief is unlikely except in mild cases when the corneal and conjunctival epithelial changes are reversible. Artificial tears, particularly preservative-free tears in more advanced cases, are the mainstay of symptomatic treatment. More prolonged duration of action can be achieved with drop preparations containing a mucomimetic such as methylcellulose, polyvinyl alcohol, or polyacrylic acid (carbomers), by using petrolatum ointment during the day and particularly during sleep, or with a hydroxypropyl cellulose (Lacrisert) insert. Mucomimetics, which also include sodium hyaluronate and autologous serum, are particularly indicated when there is mucin deficiency. If there is tenacious mucus, mucolytic agents (eg, acetylcysteine, 10% or 20% one drop six times daily) may be helpful. Additional relief can be achieved by using humidifiers, moisture-chamber spectacles, or 271 swim goggles. Disease modification can be achieved with topical anti-inflammatory agents such as corticosteroids, of which loteprednol is favored because of its low risk of intraocular adverse effects, or calcineurin inhibitors, of which cyclosporine 0. Diquafosol eye drops promote water transfer and mucin secretion in ocular tissues. Patients with excessive tear lipids may require specific instructions for removal of lipid strands from the eyelid margin. Dietary supplementation with omega-3 fatty acids or flax seed oil has been advocated to modulate favorably meibomian gland secretion. All chemical preservatives in artificial tears induce a certain amount of corneal toxicity. Patients with dry eyes from any cause are more likely to have concurrent infections. Chronic blepharitis is common and should be treated with appropriate lid hygiene and topical antibiotics as needed. Surgical treatment for dry eyes includes insertion of temporary (collagen) or extended (silicone) punctal plugs to retain lacrimal secretions. Permanent closure of the puncta and canaliculi can be achieved by thermal, electrocautery, or laser treatment. Injection of botulinum toxin into the medial lower eyelid is reported to improve discomfort by reducing tear drainage. A history of trauma or contact lens wear can often be elicited, with foreign bodies and abrasions being the two most common acute corneal abnormalities. Herpes simplex infection and corneal erosion are often recurrent, but since recurrent erosion is extremely painful and herpetic keratitis is not, they can be differentiated by the history. Use of topical medications, including nonprescription preparations, should be elicited. Topical corticosteroids predispose to bacterial, fungal, and viral disease, especially herpes simplex keratitis. Many medications and preservatives can cause contact dermatitis or corneal toxicity. The keys to examination of the cornea are adequate illumination and magnification, making the slitlamp essential. Examining the reflection as light is moved carefully over the entire cornea identifies rough areas indicative of epithelial defects. Fluorescein staining highlights superficial epithelial lesions that might otherwise not be apparent. Examination, particularly after trauma, is facilitated by instillation of a local anesthetic. Prevention, early diagnosis, and prompt management are essential to avoid long term visual impairment. Examination of corneal scrapings, using Gram and Giemsa stains, may allow identification of the organism, particularly bacteria. Cultures for bacteria, fungi, Acanthamoeba, or viruses should be undertaken at presentation if indicated clinically or later if there is lack of response to treatment. Appropriate therapy is instituted as soon as the necessary specimens have been obtained. It is important that laboratory results are interpreted in conjunction with the clinical picture. Main Risk Factors for Microbial Keratitis Contact lens wear Ocular surface disease Trauma Ocular surgery 1. This is especially true of ulcers caused by opportunistic bacteria (eg, alpha-hemolytic streptococci, Staphylococcus aureus, Staphylococcus epidermidis, Nocardia, and Mycobacterium chelonae), which often cause indolent corneal ulcers that tend to spread slowly and superficially. Pneumococcal corneal ulcer with iris prolapsing through superior peripheral corneal perforation. Pneumococcal corneal ulcer usually manifests 24–48 hours after inoculation of an abraded cornea. It typically produces a well-circumscribed ulcer that spreads from the original site of infection toward the center of the cornea. The advancing border shows active ulceration and infiltration as the trailing border begins to heal. Scrapings from the leading edge of a pneumococcal corneal ulcer usually contain gram-positive lancet-shaped diplococci. Any concurrent dacryocystitis and nasolacrimal duct obstruction should be treated. Treatment of Microbial Keratitis 283 Pseudomonas aeruginosa Keratitis Pseudomonas corneal ulcer begins as a gray infiltrate at the site of a break in the corneal epithelium (Figure 6–2). The lesion tends to spread rapidly in all directions because of proteolytic enzymes produced by the organisms. Although superficial at first, the ulcer may quickly affect the entire cornea with devastating consequences, including extensive stromal loss, corneal perforation, and intraocular infection. There is often a large hypopyon that tends to increase in size as the ulcer progresses. Pseudomonas corneal infection is usually associated with soft contact lenses, 284 especially overnight wear.
Thuja occidentalis (Arbor vitae) Constitutional remedy medications covered by medicaid buy cheap olanzapine 7.5mg on-line, especially in diseases with a tendency towards proliferative processes medicine 1900s spruce cough balsam fir olanzapine 5 mg sale, difficulty in finding words medicine ball slams olanzapine 2.5mg with visa, and other speech disorders medicine park lodging cheap 5mg olanzapine with amex, haemicrania, particularly in the left frontal eminence, malodorous perspiration. Pulsatilla pratensis (wind flower) Migrating disorders (worse before menses), dysmenorrhoea, remedy for affections of the mucous membranes, venous stasis, conjunctivitis; anxious, depressed female patients. Lachesis mutus (bushmaster) Sensation of globus, inattention to worsening condition, disorders worse in warmth from the sun, hot flushes with a sensation that clothing is too tight, garrulity, mistrust, the patient believes that he or she is being poisoned. Moschus moschiferus (musk, glandular secretion of the male musk deer) Laryngospasms, hysteria, nervous hyperactivity with tremors. Glonoinum (nitroglycerine) Palpitations extending to the neck, pulsations through the whole body, angina pectoris. Based on the individual homoeopathic constituents of Ypsiloheel, therapeutical possibilities result for the treatment of globus hystericus and other impregnation phases localized at the neck. Ypsiloheel is indicated for all manifestations of vegetative dystonia, particularly in rapidly changing disorders of the most varied nature and for irrational symptoms. Ypsiloheel is also effective for migraine, ostealgia and coronary disorders of the circulation, as well as in duodenal ulcers and parapyloric syndrome with pyrosis (auxiliary remedies are Duodenoheel, Gastricumeel, possibly Anacardium-Homaccord, Nux vomica-Homaccord, Chelidonium-Homaccord, etc. Also for chronic laryngitis and hoarseness, for struma parenchymatosa et colloides (Strumeel forte), for osteochondrosis of the cervical vertebrae with reflex symptoms of rachialgia (also globus hystericus is often caused by spondylolisthesis in the cervical region). In case vicarious headache occurs, in addition Gelsemium-Homaccord and/or Spigelon as auxiliary remedy; for dizziness: Vertigoheel. Also for climacteric neurosis, especially when cardiac symptoms are also present (palpitations extending to the neck) as well as mental alterations, Ypsiloheel (in addition to Klimakt-Heel, Nervoheel, Neuro-Injeel ampoules, Metro-Adnex-Injeel, Ovarium suis-Injeel, etc. The dosage is adjusted according to the disease, the symptoms and the state of the illness: 1 tablet dissolved on the tongue 3-4 times daily; for acute disorders, massive initial-dose therapy: 1 tablet every 15 minutes, alternating with auxiliary remedies. Contraindications: Zeel P Injection solution: Hypersensitivity to botanicals of the Compositae family or the genus Rhus of the Anacardiaceae family. Zeel T Ointment: Hypersensitivity to arnica, the genus Rhus of the Anacardiaceae family and constituents of the ointment base. Warning: In rare cases after intra-articular administration of Zeel (P) (injection solution), temporary painful joint irritation may occur, possibly with sterile effusions. Administration of anti-inflammatory medication is appropriate palliative treatment in such cases. Zeel Tablets: In general, 1 tablet to be dissolved under the tongue 3 times daily. Zeel T Ointment: Apply to the affected areas, rubbing in gently in the morning and evening, or if necessary more often, possibly applying an ointment dressing. Pharmacological and clinical notes Cartilago suis (cartilage) Arthrosis deformans, coxitis, periarthritis humeroscapularis. Funiculus umbilicalis suis (Wharton’s jelly [umbilical cord]) Damage to connective tissues, circulatory disorders. Rhus toxicodendron (poison oak) Rheumatism and neuralgia, worse in cold, wet weather; polyarthritis, diseases of the mucosa and connective tissues. Solanum dulcamara (bittersweet) Remedy to counteract the effects of wet weather, sensation of having caught a chill, rheumatic disorders. Symphytum officinale (comfrey) Injuries to the tendons, ligaments and periosteum; acts on the joints in general, neuralgia of the knee. Silicea (sillicic acid) Weakness and impairment of the connective tissues; weakness of the ligaments. Nadidum (nicotinamide adenine dinucleotide) Coenzyme, stimulation of the end oxidation in the respiratory chain. Acidum alpha-liponicum (thiotic acid) Coenzyme in the decomposition of pyruvic acid. Natrium diethyloxalaceticum (sodium oxalacetate) Active factor of the citric acid cycle and of redox systems; sensitivity to damp and wind. For the maintenance of normal articular functions, undisturbed co-ordination of the metabolism of the synovial membrane and synovial fluid on the one hand and of the arthrodial cartilage on the other, is indispensable. In the cartilage, according to the Embden-Meyerhof model, lactic acid or lactate is formed, which reaches the outer cellular layer of the joint capsule through the synovial fluid. There, by stimulation of the end oxidation through the citric acid cycle, the necessary energy is released. In arthrosis, there is a pathological alteration of the metabolism of the connective tissue in the joint (cartilage, synovial membrane and also synovial fluid), characterized by increased degradation of the connective tissue structures. This results, therefore, in disproportion between catabolic and anabolic-metabolic processes. The task of effective therapy is to normalize the disturbed metabolism, as well as offering components for possible incorporation. The decisive energy-liberating reaction of the metabolism is the formation of hydrogen, which is then transferred, to a great extent, to nicotinamide adenine dinucleotide (nadidum); thus, for example, the whole of the hydrogen liberated in the course of the citric acid cycle is transferred to nadidum, the starting member of the respiratory chain. Precisely the oxidoreduction, catalysed by nadidum, between lactic acid and pyruvic acid, or the reverse, is of decisive importance in the metabolism of the joints. Thioctic acid is also a hydrogen-transferring co-factor which, above all, participates decisively in the oxidative decarboxylation (conversion of pyruvic acid to “activated acetic acid“). In the interaction with Coenzyme A, the formation of the “activated acetic acid” is made possible which, for its part, represents the “initiator” of the citric acid cycle, while oxalacetate can be described as the fuel, or also as the engine, of the citric acid cycle. It is only through the biochemical research into mucopolysaccharide sulphates, however, that it was confirmed, i. The organ constituents provide important components of the connective tissue (cartilage, funiculus umbilicalis), while placenta pro motes the circulation and the embryo has an additional stimulating action. The botanical constituents from Rhus toxicodendron, Solanum dulcamara, Sanguinaria canadensis, Symphytum and Arnica montana are applied for rheumatic diseases of the joints, etc. The medicaments blended into a pharmacologically active and non-toxic combination in Zeel, on the basis of many years’ medical experience and the most recent biochemical research form a highly valuable remedy for chronic diseases of the joints, as can be seen from the composition and from what has been confirmed by clinical and practical tests. Based on the individual homoeopathic constituents of Zeel, therapeutic possibilities result for the treatment of arthrosis (in particular gonarthrosis), polyarthrosis, spondylarthrosis, periarthritis humeroscapularis. The dosage is adjusted according to the disease, the clinical picture and the stage of the illness: 1 tablet to be dissolved on the tongue 3-5 times daily. The ointment should be applied or rubbed in morning and evening and, if necessary, more often, at the affected areas, possibly using an ointment dressing. Indications: Arthrosis (in particular gonarthrosis); polyarthrosis, spondylarthrosis, scapulohumeral periarthritis. Contraindications: Hypersensitivity to botanicals of the Compositae family or the genus Rhus of the Anacardiaceae family. Package sizes: Injection solution: Packs containing 10, 50 and 100 ampoules of 2,0 ml. Pharmacological and clinical notes Rhus toxicodendron (poison oak) Rheumatism and neuralgia, worse in cold, wet weather; polyarthritis, diseases of the mucosa and connective tissues. Arnica montana (mountain arnica) To stimulate the healing of wounds, rheumatism, injuries arising from falls, blows or contusions; pains in the back and limbs. Sanguinaria canadensis (blood-root) Neuralgic and rheumatoid pains of the joints and muscles. To facilitate searching for a specific product, this section provides a complete alphabetical listing of Heel’s single-constituent remedies. Classical homoeopathic single-constituent remedies including “Injeels“ available in “standard“ and “forte“ strengths, and standard single potencies. The composition and a short summary of indications are given for these popular preparations. Composition of single-constituent remedies With the exception of the single potencies, the single remedies contain balanced potency chords: A balanced potency chord consists of several potencies of one and the same constituent. The individual potencies retain their independent action even when blended together (G. A forte potency chord generally contains the potencies of the standard chord plus one lower potency. Unless stated otherwise, the different potencies are contained in equal quantities, which add up to 1. Particulars of the composition and indications are only given for the classical homoeopathic single remedies but not for the homoeopathically adjusted allopathic remedies, catalysts, nosodes, and suis-organ preparations. Type of administration and dosage of single remedies the single remedies can be injected i. In acute disorders, 1 ampoule 3-1 times daily intramuscularly, subcutaneously, intradermally (segmentally) or intravenous. Homoeopathically adjusted allopathic remedies: 1 ampoule 2 times weekly intramuscularly, subcutaneously, intradermally or intravenous.
Diseases
- Onychocryptosis
- Riley Day syndrome
- Dependent personality disorder
- Myocarditis
- Crisponi syndrome
- Retrograde amnesia
- Microcephaly with normal intelligence, immunodeficiency
- Aughton syndrome
- Oral facial digital syndrome type 3
- Gamborg Nielsen syndrome
This period coincided with the development of stress models and the biopsychosocial model; in each case symptoms bipolar purchase olanzapine 10mg amex, scholars expanded their models to medicine 0552 buy generic olanzapine 2.5 mg on line allow for interdisciplinary research on health in the body medications without doctors prescription purchase olanzapine uk. The modern definition of bioarchaeology exemplifies a similar shift toward more interdisciplinary and scientific research in the study of health in ancient human remains treatment 4 hiv buy cheap olanzapine 5 mg online. The first application of the term “bioarchaeology” to the study of human remains in archaeological contexts was made by Buikstra (1977, 67)17 as part of a larger conference volume (Blakely 1977a) that focused on the ways bioarchaeologists can study human remains to explore social issues. In this volume, Blakely emphasizes the use of interdisciplinary approaches, and argued that biological anthropologists can contribute to illustrating “the interrelationships between the biological, cultural, and environmental variables that affect the adaptedness or maladaptedness of prehistoric populations” (Blakely 1977b, 3). Essentially, this volume represented a broader emphasis in bioarchaeology to unify studies on biology and culture, a “biocultural approach,” which made bioarchaeology particularly well-suited to theoretically address health as a product of society. Methodologically, the field also developed in the 1960s and 1970s, with a growth in studies on ways non-specific stress manifests in human remains. These methods provided the foundations for a broader analysis of generalized stress in bioarchaeology, which was crystalized at a much grander scale in the conference volume Paleopathology at the Origins of Agriculture (Cohen and Armelagos 1984). In this volume, the “systemic stress model” was formalized by Goodman and colleagues (1984). Since then, this model has been adapted and most prominently utilized at an international scale in the Backbone of History (Steckel and Rose 2002), a comprehensive diachronic study on health in the Western Hemisphere. Stemming from this project, the Global History of Health Project offers a complementary European module on health data from prehistory to the modern era (Steckel 2003). It is thus inversely correlated to health status, where higher health status is affiliated with lower amounts of stress. By modelling these kinds of systemic stress, it is possible to assess the overall stress an individual experienced rather than looking for the specific etiologies of individual diseases. This is advantageous as it (1) does not require correct identification of specific diseases in order to assess health status, (2) considers the multiple and compounding effects of more than one stress on an individual, and (3) allows consideration of the many illnesses which do not result in diagnostic skeletal lesions. In essence, the systemic stress model is a perfect metric for 18 Non-specific stress markers are described in more detail in chapter six. The general stress model aims to document the relationship between culture and biological health in several ways. First, it demonstrates the underlying effects of culture on biological health as “the severity and duration of the stress response may be viewed as a function of the degree of cultural and environmental constraints and stresses, balanced against the adequacy of the cultural buffering system and individual resistance resources” (Goodman and Martin 2002, 18). Cultural buffering systems are designed to reduce the amount of biological stress an individual experiences, such as clothing designed to minimize stress from the local climate. I suggest that health care networks within a culture are a complex form of a buffering system, designed to respond to stress in order to mollify and reduce it. Consequently, the health status of an individual not only reflects the amount of stress they experienced, but the efficacy of these cultural buffering systems and health care networks in alleviating stress. Second, the general stress model can reveal culturally relevant trends affecting health status. It can assess whether some cultural groups experienced significantly more stress than others, and consequently highlight differences in the availability and efficacy of these cultural buffering systems. Finally, the general stress model allows us to assess some basic differences in the primary sources of stress between disease, nutrition, and occupation. Some markers, such as linear enamel hypoplasias, are associated with early childhood illness (Goodman and Martin 2002, 23), while others, such as degenerative joint disease, are characteristic of adult behavioral stress. These differences further help to explain overall differences in health status within a population by differentiating the amount of stress experienced as children and adults. The vertical axis focuses on how the biopsychosocial model can link the body with health within society. The horizontal axis focuses on how theoretical models within anthropology describe health care as processes of diagnosis and treatment. The texts and human remains at Deir el-Medina 33 are specifically well-situated within this framework to access health status and health care at Deir el-Medina. The texts give us insight into the horizontal axis starting at the level of the individual. At this level, individual descriptions of illness and treatment serve as the basis for explanatory models of disease. When these are combined in comprehensive medical texts, they create a disease theory (chapter three). The disease of an individual can be treated through a network of popular, professional, and folk practitioners. Texts discussing taking care of others through provisioning and nursing (popular health care), as well as texts describing the activities of medical practitioners (professional and folk health care), define how these different sectors of health care overlap and interact (chapter four). Sick days recorded in absence from work texts provide specific, individual days of illness. I can evaluate them within the context of the physical and social place of the broader community to explain how sickness impacted the workforce (chapter five). It is also on the vertical axis that the human body gives us unique insight into health, beginning with a pathological lesion as a direct manifestation of disease. Through identifying these lesions as either diagnostic indicators of pathology or non specific stress indicators (chapter six), I can determine physical abnormalities in the body. At the level of an individual, these metrics can be used to quantify illness (chapter seven), which in turn delimits impairment. At the community level, these quantifications can then be compared both within Egypt and to broader populations in order to situate sickness at Deir el-Medina within a comprehensive cultural landscape (chapter eight). When these different data sets are combined, they create a rich 34 illustration of the ways biology and culture interact to impact both health status and health care at Deir el-Medina (chapter nine). This system allows us to define medicine as anything designed to treat illness, and thus can include both proactive and reactive treatments. In this chapter, I explore emic perceptions of illnesses at Deir el-Medina as evidenced through texts from the village itself and broader medical texts which explicate concepts surrounding illness and health care in Egypt during the New Kingdom and Third Intermediate Period. This chapter begins with an analysis of the Egyptian theory of disease transmission as evidenced in the Oracular Amuletic Decrees and medical texts. The former can be used to explain the agency of illness in Egypt—who or what caused illness and why. The latter, which were written as manuals for diagnosing and treating illnesses, offers information on how individuals became ill through explaining the modes of transmission, interaction, and eradication of disease. Through a combined analysis of these texts, I demonstrate that the dominant theory of disease transmission in Egypt was founded upon a concept of contamination, whereby the body could be contaminated by a variety of agents, ranging from infection by divine semen to the internal corruption of the body itself. I then use medical texts to demonstrate that contamination theory dictated logical arguments used in medical treatments, whereby medicine was designed to 36 remove contaminants from the body through purging, purification, and ritual sealing to prevent re-contamination. Finally, I present texts from Deir el-Medina specifically relating to medical prescriptions and treatment to evidence how medicine was practiced in daily life. By contextualizing medicine to its use at Deir el-Medina, I demonstrate that medical archives were developed in discrete increments, and likely reflected the specific needs of a family or community, rather than being built as a generic compendium. Through analysis of amuletic medical texts, I demonstrate that because medical care was aimed at decontaminating individuals, treatments were specialized to cure one illness in one individual. This highly personalized medical care meant that when these treatments were not provided by the state, they would have been almost exclusively accessible to the literate. Moreover, the careful maintenance of these texts in combination with the use of esoteric and specialized language restricted broader medical archives to the most knowledgeable and literate members of a community. As Lang notes in her discussion of Pharaonic medicine,19 “Explicit references to physiological and pathological ideas are present but rare, and theory is not discussed in detail in any extant work. Many of the terms used—whether for disease, disease causes, bodily organs, symptoms, or ingredient in remedies—do not occur outside the medical texts and are of uncertain and possibly multiple meanings 19 While Lang’s book is focused on Ptolemaic medicine, she includes extensive sections on Pharaonic medicine. All references to Lang in this dissertation are from these sections of her publication. While an overarching theory of disease transmission is still noticeably absent in current research (as noted by Fischer-Elfert 2009, 49; and Quack 2003), specific studies have begun to explore Egyptian perceptions of the body, disease, and medicine. For example, individual articles have informed us about Egyptian ideas regarding airborne infection from demons (Engelmann and Hallof 1996), internal pain processes (Gordon and Schwabe 2004; Kolta and Tessenow 2000), and the introduction of a foreign disease into Egypt (Fischer-Elfert 2011). The following discussion incorporates several of these studies in order to construct a cohesive Egyptian theory of disease transmission. My point is not to determine a simple and universal source for all diseases, an approach criticized by Quack (2003, 12), but rather to identify an overarching logic that explains the etiology and therefore treatment of illness in general. This serves as one of possibly multiple disease theories that cohesively act as cultural explanations of illness causation in ancient Egypt. Both were designed to offer comprehensive protection and treatment from the many and varied threats to an individual’s health.
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