An anal fistula is an abnormal connection between the epithelialised surface of the anal canal and (usually) the perianal skin.

Anal fistulae originate from the anal glands, which are located between the two layers of the anal sphincters and which drain into the anal canal. If the outlet of these glands becomes blocked, an abscess can form which can eventually point to the skin surface. The tract formed by this process is the fistula.

Abscesses can recur if the fistula seals over, allowing the accumulation of pus. It then points to the surface again, and the process repeats.

Anal fistulas per se do not generally harm and they often do not hurt, but they can be irritating because of the pus-drain (and, it is not unknown for formed stools to be passed through the fistula); additionally, recurrent abscesses may lead to significant short term morbidity from pain, and create a nidus for systemic spread of infection.

Surgery is considered essential in the decompression of acute abscesses; repair of the fistula itself is considered an elective procedure which many patients elect to undertake due to the discomfort and inconvenience associated with a draining tract.

A fistula in ano is a tunnel like- pipe like track, developed in the perennial region, usually having one or more external openings around the anus leading to an internal opening in the mucosa of the anal canal or the rectum.

Anal fistula is termed “Bhagandara” in Ayurveda. In Ayurveda fistulas, like other diseases have been classified according to the vitiation of one per more of the three doshas i.e. the vata, the Pitta & the kapha. They have been classified also according to the shape & site of the track of the fistula. Special treatment for such different kinds of fistulas is mention in detail. It is worth noting that the complex & most challenging horse shoe fistula ( complex Ischio-rectal fistula) has been dealt with in detail in Sushruta a classical Ayurveda text) even as early as 300 ad.

The Ksharsutra treatment was probably first advised per this type of fistula named Parikshepi Bhagandara by Sushurta. This Ksharsootra treatment, with a little modification has proved its worth even in modern times.

Anal fistula, a rare condition, is a chronically inflamed, abnormal tunnel between the anal canal and the outer skin of the anus. It often drains watery pus, which can irritate the outer tissues and cause itching and discomfort.

How does it occur?

An anal fistula usually results from an infection that forms in the tissue lining the anal canal. The infection may be caused by spread of bacteria that normally exist in the rectum. Occasionally, it may occur as a result of :

• A healed sore in the rectal area
• Ulcerative colitis, a disease associated with ongoing breakdown of tissues that causes a sore in the lining of the colon
• Diverticulitis, inflammation of harmless growths in the wall of the intestines
• Crohn’s disease, a chronic inflammation of the intestines
• Tuberculosis
• Gonorrhea
• Cancer of the large intestine.

What are the symptoms?

Symptoms of anal fistula may include :

Itching, discharge of watery pus, irritation of tissue around the anus, discomfort & pain these are the main symptoms of the fistula in ano

Other Symptoms

Anal fistulae can present with many different symptoms:

• Pain
• Discharge - either bloody or purulent
• Pruritus ani - itching
• Systemic symptoms if abscess becomes infected

Diagnosis

Diagnosis is by examination, either in an outpatient setting or under anaesthesia (referred to as EUA - Examination Under Anaesthesia). The examination can be an anoscopy.

Possible findings:

• The opening of the fistula onto the skin may be seen
• The area may be painful on examination
• There may be redness
• An area of induration may be felt - thickening due to chronic infection
• A discharge may be seen
• It may be possible to explore the fistula using a fistula probe (a narrow instrument) and in this way it may be possible to find both openings of the fistula

How is it diagnosed?

Causes

However in most cases there are no definite causes found.

Possible contributing factors

Guide lines to approach an expert for investigating a possibility of anal fistula.

Recurrent boils developing at the same site. (around the anus)

Treatment

There are several stages to treating an anal fistula:

Treating active infection

Some patients will have active infection when they present with a fistula, and this requires clearing up before definitive treatment can be decided.

Antibiotics can be used as with other infections, but the best way of healing infection is to prevent the buildup of pus in the fistula, which leads to abscess formation. This can be done with a seton - a length of suture material looped through the fistula which keeps it open and allows pus to drain out. In this situation, the seton is referred to as a draining seton.

Definitive treatment

Definitive treatment of a fistula aims to stop it recurring. Treatment depends on where the fistula lies, and which parts of the anal sphincter it crosses.

There are several options:

• Doing nothing - a drainage seton can be left in place long-term to prevent problems. This is the safest option although it does not definitively cure the fistula.

• Lay-open of fistula-in-ano - this option involves an operation to cut the fistula open. Once the fistula has been laid open it will be packed on a daily basis for a short period of time to ensure that the wound heals from the inside out. This option leaves behind a scar, and depending on the position of the fistula in relation to the sphincter muscle, can cause problems with incontinence. This option is not suitable for fistulas that cross the entire anal sphincter.

• Cutting seton - if the fistula is in a high position and it passes through a significant portion of the sphincter muscle, a cutting seton may be used. This involves inserting a thin tube through the fistula tract and tieing the ends together outside of the body. The seton is tightened over time, gradually cutting through the sphincter muscle and healing as it goes. This option minimizes scarring but can cause incontinenceflatus (wind). Once the fistula tract is in a low enough position it may be laid open to speed up the process, or the seton can remain in place until the fistula is completely cured. in a small number of cases, mainly of

• Fibrin glue injection is a method explored in recent years, with variable success. It involves injecting the fistula with a biodegradable glue which should, in theory, close the fistula from the inside out, and let it heal naturally. This method is perhaps best tried before all others since, if successful, it avoids the risk of incontinence, and creates minimal stress for the patient.
• Fistula plug is an “advanced” version of the fibrin glue method. It involves “plugging” the fistula with a “plug” made of porcine small intestine submucosa (sterile, biodegradable), fixing the plug from the inside of the anus with suture, and, again, letting the fistula heal “naturally” from the inside out. According to some sources, the success rate with this method is as high as 80%.
• Endorectal advancement flap is a procedure in which the internal opening of the fistula is identified and a flap of mucosal tissue is cut around the opening. The flap is lifted to expose the fistula, which is then cleaned and the internal opening is sewn shut. After cutting the end of the flap on which the internal opening was, the flap is pulled down over the sewn internal opening and sutured in place. The external opening is cleaned and sutured. Success rates are variable and high recurrence rates are directly related to previous attempts to correct the fistula.
• Anal Fistula Plug is a recently developed method known as AFP. This treatment requires placement and fixing of a plug in the anal fistula by a special technique. One advantage of this method is that it involves no cutting, so there is no post operative wound and pain. AFP plugs can sometimes be inserted under local anesthesia. This method can be used successfully to treat high fistula without colostomy. It does not carry any risk of bowel incontinence. As opposed to the staged operations, which may require multiple hospitalizations, AFP requires hospitalization for only about 24 hours. Currently, there are two different anal fistula plugs cleared by the FDA for treating ano-rectal fistulas in the United States.

Other Modes of treatments

Anal fistulas are almost never found to heal spontaneously. The inner wall of the fistula develops fibers tissue & payogenic membrane not allowing spontaneous healings.

Ayurveda has a unique way of treating fistula in ano. Simple as well as complex fistulas, high anal fistulas, fistulas with multiple track, recurrent fistulas, chron’s fistula, tubercular fistula, all respond well to the Ksharsutra ligation procedure.

What is Ksharsutra / Ksharsootra?

The Ksharsootra /Ksharsutra is a type of thread / medicated setone prepared by coating and recoating the thread 15 to 21 times with different drugs of plant origin. The mechanical action of the treads and the chemical action of the drugs coated on the thread, to gather do the work of cutting, curetting, draining, and cleaning the fistulous track, thus promoting healing of the track/ wound.

And natural antibiotic like haridra powder, guggulu, etc are used in the preparation of different kind of Ksharsutra. It takes a number of days to prepare this Ksharsutra since the previous coat has to dry before the next is applied.

Different kinds of Ksharsootra are prepared using different drugs. These Ksharsutra are passed through the track (usually under short anesthesia) and the two ends of the thread are tied forming a loop. The drugs coated on the thread are continually released through out the length of the track there by cutting, curetting, draining cleansing and healing the track simultaneously in the track after about eight days the thread loosens because it has cut through some of the tissues and also is now almost bare ( with no drugs on it). A new thread is now replaced in the track by a special method. The changing of the thread is a simple opd procedure taking about 1 to 2 minutes and requires no anesthesia. (See the procedure). the thread gradually cuts through the tissue. The tissues above the thread heal up. Hence when at last the loop of thread comes out, the track is healed.

Ksharsootra (medicated setone) therapy is practiced in India since times immemorial. Modified and revived by the late Dr. P. J. Deshpande. The Ksharsootra therapy is a unique treatment of Ayurveda gaining popularity globally.

Special types of medicated setone are used in this procedure Found to be effective in any ano rectal conditions, it has many advantages in the treatment of Anal fistulae.

Benefits of the ksharsutra ligation procedure over other methods

The Ksharsootra ligation method is an age old, time tested procedure originally performed by Sushruta (the father of surgery) around 300 ad. The fact that it is still in practice to day is a proof in it self of its efficacy.

How can i take care of myself ?

Some tips to prevent cramping:

• warm up first, don’t do a lot of sit-ups all at once. then start em out in really small numbers, after a few, roll over and do a cat stretch (lay on your stomach, feet/legs togeather, put your hands down by your sides, then stretch up, straight arms, and lean back, like a kitty stretching.  Then, do cool down at the end too.
• don’t drink too much cold water especially just before exercising.
• don’t do these crunches right after you eat
• You just need to build up your core and gradually progress up to more reps. Do your 10 crunches several times a week, then try to do a couple more the next week and so on.
• You can experiment with making efforts to stay hydrated, for example, by supplementing your diet with bananas (for the potassium) and refueling with ergogenic drinks to replace electrolytes. These techniques don’t always prevent cramping, but they are worth trying.
• When the cramps do occur, you should lay flat on your back, or stand up straight, and reach your arms over your head until the cramp resolves. Reaching overhead stretches the abdominal muscles and releases the cramp.
  

The area that probably generates the most debate? Knowing what to eat. There is such an abundance of contradictory studies about food and cancer that it’s nearly impossible to consider any one definitive, let alone keep them all straight. So how do you sort through myriad studies, complete with caveats and exceptions? Well, you don’t, because we did it for you. SELF went to the experts and scrutinized the latest research to summarize the best cancer-fighting eating advice so far. We also looked at the news on other lifestyle factors such as stress and exercise to generate a guide that can help cancer-proof your body from head to toe. But first, a list that tells you what to forgo and what to fill up on. Let’s eat!

Three foods to feast on frequently

Cruciferous veggies. Broccoli, brussels sprouts, cabbage, cauliflower and kale are all cancer-fighting stars in the produce department, and several studies have linked them to a lower risk for colorectal, lung and stomach cancers, says Lawrence Kushi, Sc.D., associate director for epidemiology at Kaiser Permanente in Oakland , California . Plus, research from Michigan State University in East Lansing found that those who ate raw or lightly cooked cabbage and sauerkraut more than three times a week were 72 percent less likely to develop breast cancer than those who had 1.5 or fewer servings. Experts suspect vegetables such as cabbage contain chemicals that turn on your body’s natural detoxifying enzymes, Kushi explains.
How much to eat. You can’t have too much, but five weekly half-cup servings is a reasonable goal.

High-fiber anything. Fiber’s ability to keep things moving appears to have a protective effect not only on the colon (no surprise) but also on the breasts. Researchers in Sweden followed more than 61,000 women and discovered that those who consumed more than 4.5 servings of whole grains daily had a 35 percent lower risk for colon cancer. Because fiber speeds the passage of stool through the colon, cells have less exposure to potentially carcinogenic waste. Roughage may also sop up excess estrogen and insulin, two hormones linked to breast cancer.

How much to eat. Aim for 25 grams (from food) a day. A half cup of a high-fiber cereal, such as All-Bran or Fiber One, can provide about half your daily dose. Beans, whole-grain breads with added fiber, fruit and veggies can help get you there, too.

Foods rich in vitamin D and calcium. Your breasts and colon may get protection from this vitamin/mineral combo. Scientists who reviewed 10 studies found that those who consume high amounts of dairy products have a lower risk for colorectal cancer, likely because of calcium’s protective effect, according to a report in the Journal of the National Cancer Institute. The two nutrients may also help ward off early breast cancer by suppressing the effects of hormones.

How much to consume. Women under 50 need 1,000 milligrams of calcium and at least 400 international units of vitamin D a day. Fortified milk and orange juice are good sources of both.

Two foods to enjoy often

Tomatoes and berries. There’s a bit of evidence that tomatoes and tomato products may reduce the risk for gastric, ovarian, pancreatic and prostate cancers. The theory: Lycopene, which gives tomatoes their red color, may help prevent cell damage. The research, however, is far from proven. “It is one thing to show effects in tissue culture, and another thing to demonstrate conclusively that these effects translate into real health effects in people,” Kushi says. Still, these foods are absolutely healthy, so SELF says, Eat them!

Berries, too, have their share of fans, but evidence of their anticancer benefits is still being gathered. Certainly, strawberries, raspberries and blueberries are rich in antioxidants, which protect against cell damage. But as with tomatoes, it’s not clear if the findings hold up in the real world. Again, this is not a time to wait for the science to catch up — consuming a variety of fruit and veggies will always be good for you.

How much to eat. Make berries and tomatoes a part of your nine fruit and veggie servings a day. Sneak in extra amounts by tossing some berries on your cereal or ordering a little extra sauce for your pasta.

Three foods to cut back on

Red and processed meat. Still reluctant to trade your hot dog for a not dog? You may want to reconsider. Studies have found a strong connection between colon cancer and processed meat such as hot dogs and cold cuts, as well as beef, pork and lamb. The stats are pretty convincing: Women who ate approximately 1 ounce of processed meat (about one slice of bologna) two or three times a week for a decade were 50 percent more likely to develop colon cancer; eating only 2 ounces of red meat a day long-term can increase the odds of rectal cancer by as much as 40 percent, according to a large study in The Journal of the American Medical Association. Colon cancer isn’t a carnivores-only concern. Women who downed 1.5 servings of meat a day had nearly twice the breast cancer risk of those who ate fewer than three servings per week, according to a study in the Archives of Internal Medicine. One possible reason? Carcinogens are created when meat is cooked at high temperatures as well as when it’s processed with substances such as nitrates.

How much to eat. Think of meat as a side dish, Kushi says. Stick to less than 3 ounces of red meat a day, and avoid charring as much as possible.
Alcohol. Disconcerting news for drinkers: Imbibing alcohol increases the risk of developing breast, colon, esophagus, mouth and throat cancers. “Alcohol is one of the few dietary factors showing a clear and consistent relationship with breast cancer,” Kushi says. If you’re wondering why total abstinence isn’t encouraged, the reason is twofold: “We recognize that a little bit of alcohol reduces risk for cardiovascular disease,” Kushi says. Plus, there’s nothing wrong with enjoying life!

How much to down. It’s safest to limit yourself to a drink a night, max — and less if you have a significant risk for breast cancer. Because binge drinking may have other negative health consequences, no divvying up your seven drinks over two days instead of seven. (We asked.)

Fats. Although experts agree that maintaining a diet low in saturated fat is smart all around, the research linking fat and cancer is controversial. Still, there is evidence suggesting that keeping fat intake low may offer some breast cancer protection. When researchers from the National Cancer Institute in Bethesda , Maryland , followed nearly 189,000 postmenopausal women for four years, they discovered that the chance of developing breast cancer was 15 percent higher among women whose diets were 40 percent fat versus those that were 20 percent.

How much to eat. No more than 30 percent of your calories should come from fat. That’s about 60 grams of fat for women eating 1,800 calories a day. And because saturated fat plays a huge role in heart disease, try to get most of your fat from healthy sources such as avocados, fish, nuts and olive oils.
One food to watch carefully

Soy. Soy is generally good for you, but its exact relationship with breast cancer is still being sussed out. Studies in the lab show that breast cancer cells proliferate when exposed to isolated soy compounds, most likely because soy contains plant-based estrogens, Kushi says. In the body, however, “these same phytoestrogens seem to be related to some reduction in risk.”

How much to eat. About 20 grams or less daily. You’ll be in the healthy range with a cup of tofu, three quarters of a cup of edamame, about half a cup of tempeh or a quarter cup of soy nuts.

2) “The Sexual Teaching of the JadeDragon: Taoist Methods for Male Sexual Revitalization” by Hsi Lai; published by Destiny Books of  Rochester, Vermont

3) “The Sexual Teachings of the White Tigress” by Hsi Lai; published by Destiny Books of Rochester, Vermont

4) “Sex, Health, and Long Life: Manuals of Taoist Practice” translated by Thomas Cleary

5) “Taoist Secrets of Love: Cultivating Male Sexual Energy” by  Mantak Chia & Michael Winn

6) “Healing Love through the Tao: Cultivating Female Sexual Energy” by Mantak Chia

7) The Tao of Love and Sex by Jolan Chang

The Tao of Loving Couple: True Liberation Through the Tao by Jolan Chang

9) The Food of Love and Sex: The Tao of Loving, Living and Eating by Jolan Chang

10) White Tiger, Green Dragon: A Tale of the Taoist Inner Alchemy (Paperback) by Simone Marnier

11) Black Tortoise, Red Raven: The Sequel to White Tiger, Green Dragon by Simone Marnier

Lodamin is an angiogenesis inhibitor that Folkman’s team has been working to perfect for 20 years. Writing in the journal Nature Biotechnology, his colleagues say they developed a formulation that works as a pill, without side-effects.

They have licensed it to SynDevRx, Inc, a privately held Cambridge, Massachusetts biotechnology company that has recruited several prominent cancer experts to its board.

Tests in mice showed it worked against a range of tumors, including breast cancer, neuroblastoma, ovarian cancer, prostate cancer, brain tumors known as glioblastomas and uterine tumors.

It helped stop so-called primary tumors and also prevented their spread, Ofra Benny of Children’s Hospital Boston and Harvard Medical School and colleagues reported.

“Using the oral route of administration, it first reaches the liver, making it especially efficient in preventing the development of liver metastasis in mice,” they wrote in their report. “Liver metastasis is very common in many tumor types and is often associated with a poor prognosis and survival rate,” they added.

‘ALMOST CLEAN’ LIVERS

“When I looked at the livers of the mice, the treated group was almost clean,” Benny said in a statement. “In the control group you couldn’t recognize the livers — they were a mass of tumors.”

The drug was known experimentally as TNP-470, and was originally isolated from a fungus called Aspergillus fumigatus fresenius.

Harvards’s Donald Ingber discovered the fungus by accident while trying to grow endothelial cells — the cells that line blood vessels. The mold affected the cells in a way known to prevent the growth of tiny blood vessels known as capillaries.

Ingber and Folkman developed TNP-470 with the help of Takeda Chemical Industries in Japan in 1990.

But the drug affected the brain, causing depression, dizziness and other side-effects. It also did not stay in the body long and required constant infusions. The lab dropped it.

Efforts to improve it did not work well. Then Benny and colleagues tried nanotechnology, attaching two “pom-pom”-shaped polymers to TNP-470, protecting it from stomach acid.

In mice, the altered drug, now named lodamin, went straight to tumor cells and helped suppress melanoma and lung cancer, with no apparent side effects, Benny said.

All untreated mice had fluid in the abdominal cavity, and enlarged livers covered with tumors. Mice treated with lodamin had normal-looking livers and spleens, the researchers said.

Twenty days after being injected with cancer cells, four out of seven untreated mice had died, while all treated mice were still alive, Benny’s team reported.

“I had never expected such a strong effect on these aggressive tumor models,” she said. The researchers believe lodamin may also be useful in other diseases marked by abnormal blood vessel growth, such as age-related macular degeneration.

Evening at 9 - 11pm: is the time for eliminating unnecessary/ toxic chemicals (detoxification) from the antibody system (lymph nodes). This time duration should be spent by relaxing or listening to music. If during this time a housewife is still in an unrelaxed state such as washing the dishes or monitoring children doing their homework, this will have a negative impact on health.

Evening at 11pm - 1am: is the detoxification process in the liver, and ideally should be done in a deep sleep state.

Early morning 1 - 3am: detoxification process in the gall, also ideally done in a deep sleep state.

Early morning 3 - 5am: detoxification in the lungs. Therefore there will sometimes be a severe cough for cough sufferers during this time. Since the
detoxification process had reached the respiratory tract, there is no need to take cough medicine so as not to interfere with toxin removal process.

Morning 5 - 7am: detoxification in the colon, you should empty your
bowel.

Morning 7 - 9am: absorption of nutrients in the small intestine, you should be having breakfast at this time. Breakfast should be earlier, before 6:30am, for those who are sick. Breakfast before

7:30am is very beneficial to those wanting to stay fit. Those who always skip breakfast, they should change their habits, and it is still better to eat breakfast late until 9 - 10am rather than no meal at all.

Sleeping so late and waking up too late will disrupt the process of removing unnecessary chemicals. Aside from that, midnight to 4:00 am is the time when the bone marrow produces blood. Therefore, have a good sleep and don’t sleep late.

“Down on top of the head and up between the groin!” urges instructor Debra Stewart, of nearby Chung’s Academy of Martial Arts, commanding a dozen gray-haired students swinging canes at imaginary attackers. “Stomp him! Dig it in there. Do it hard!”

Watch demonstrations of cane defense moves.

Jim Ghory, an 82-year-old retired toolmaker, volunteers to take a few demonstration shots at Ms. Stewart, who has a black belt in tae kwon do, a Korean martial-arts discipline. “You want [it in] the collarbone or the ribs?” he asks.

Senior centers and retirement communities are looking for new ways to promote exercise in order to stave off physical decline. Older people interested in honing their self-defense skills, meanwhile, are delighted to find that something they already own can be used as a weapon.

“Oh my gosh, it’s a huge hit,” says Lena Mast, manager at Lodges at Naylor Mill, an independent-living complex for seniors in Salisbury, Md. Ms. Mast began offering cane classes for residents in April and says “it’s now the top thing they look forward to.”

Mitchell’s Martial Arts, the school hired by Lodges, says it is teaching cane fighting at five senior centers a week, up from one last year, and also has been demonstrating the cane at local health fairs. Cane Masters, in Incline Village, near Reno, Nev., one of a number of schools that report rising demand from seniors, expects to teach 110 cane-fighting classes around the country this year.

Martial Oceans International, a California cruise company, is planning to offer its first classes in cane fighting on a trip to Mexico this month. On YouTube, a video titled “Granny C. Takes on the BulletMan!” shows an agile woman in her seventies jabbing and taking down a man in a helmet pretending in a cane class to be an intruder.

Many credit the rise of cane fighting to Mark Shuey, a 61-year-old tae kwon do and hapkido expert who owns Cane Masters. Mr. Shuey started studying cane moves in earnest about 10 years ago while practicing hapkido, which incorporates stick fighting at advanced levels. At the time, his father was starting to use a walking stick, and he had heard reports of attacks on seniors who carried canes but didn’t know how to use them to fight back. By 2003, the Canadian magazine Martial Arts Experts was calling canes “the weapon you can take anywhere.” Cane fighting, also called “combat” cane or “cane fu,” has been endorsed by at least eight martial-arts organizations.

Instructors say any kind of cane is fine for self-defense, including aluminum canes or the wooden canes made of pine available at the drugstore. But best are hard-wood canes made of hickory or oak that don’t easily break on impact.

Mr. Shuey travels the world teaching his “American Cane System” curriculum to other martial-arts teachers. He says that in two years the number of instructors who teach it has tripled to about 300.

The cane has a rich history as a weapon, notably in the U.S. Capitol. A number of 19th-century canings at the Capitol included a brutal 1856 attack on the Senate floor by South Carolina Rep. Preston Brooks on abolitionist Massachusetts Sen. Charles Sumner, who had mocked a relative of Mr. Brooks in a speech. Mr. Sumner was carried away unconscious and bleeding. It took him years to recover.

Most of the seniors who take cane classes rarely wield them against anyone. But Bill Carter, a 56-year-old who took a class from Mr. Shuey in Florida a few years ago, says the instruction came in handy one day in April last year when he walked into his house in suburban Jacksonville to find an intruder in his kitchen taking TV dinners from the freezer. As the man approached him, “I popped him on the kneecap,” Mr. Carter says, and “hooked him behind the neck, and was able to guide him to the door.”

Cane-fighting converts say one of the best things about the cane is that it’s a legal weapon that can be carried anywhere, unconcealed. “No one will tell you can’t take it on an airplane,” says Victor Cushing, a 68-year-old who teaches women’s self-defense at the University of Scranton, in Pennsylvania.

The Department of Homeland Security says it does allow canes as carry-ons on planes. “Just like we allow walkers or crutches,” says Carrie Harmon, spokeswoman for the Transportation Security Administration, a division of the department. But, she cautions, all these devices “have to go through the X-ray machine.”

According to the agency, baseball bats, cricket bats, bows and arrows, golf clubs, hockey sticks, pool cues, axes, hatchets, cattle prods, crowbars, billy clubs, brass knuckles, meat cleavers, ice picks, pellet guns, stun guns, spear guns, saws, swords, sabers and snow globes are also allowed — but they must ride in the luggage compartment.

Mr. Cushing doesn’t need a cane for support but totes one everywhere. His repertoire of moves includes “bopping” the fragile bones on top of the foot (”now you’ve got an attacker who’s limping away”), or whipping it against the shins (”hurts like the devil”).

Senior centers refer to cane classes as a gentle form of exercise. But Mr. Cushing worries that some instructors are teaching overly fancy moves that could make older people lose their balance. Swinging the cane against the shins is one thing, he says, but “if you actually need the cane for balance, you can’t be swinging it in the air.” You’ll fall over.

Carol Vincent, an 85-year-old retired teacher, joined the classes at St. Leonard’s, in Centerville, to feel safer on her daily walks in the woods. Ms. Vincent says she realized her own strength in an exercise where she had to use her cane to break the grip of a classmate who grabbed her from behind. “I think I hurt one woman,” she said. “She’s never been back; I shouldn’t have pulled the cane so hard.”

John Myers, 66 and retired from a plant that made oil seals, was grabbed around the neck in a mock attack by Ms. Stewart’s fellow instructor, Bob Dempsey. Mr. Myers’s face reddened. He could feel himself getting angry. “I wanted to hit him,” Mr. Myers said later.

Instead, he used his cane to pull down and break his attacker’s grip. Ms. Stewart coached, “Stomp on his foot, which is going to create some pain!” He did. Then, as taught, Mr. Myers jabbed the cane’s tip behind him, into Mr. Dempsey’s ribs. Mr. Dempsey fell back, feigning defeat, but later he described Mr. Myers as “ferocious.”

“He could take me down,” Mr. Dempsey said.

Today obstetricians, surgeons and other doctors might consider reviving the practice. Over the past three years, some 7,000 M.D.s have flooded into Texas, many from Tennessee.

Corbis

Sam Houston.

Why? Two words: Tort Reform.

In 2003 and in 2005, Texas enacted a series of reforms to the state’s civil justice system. They are stunning in their success. Texas Medical Liability Trust, one of the largest malpractice insurance companies in the state, has slashed its premiums by 35%, saving doctors some $217 million over four years. There is also a competitive malpractice insurance industry in Texas, with over 30 companies competing for business. This is driving rates down.

The result is an influx of doctors so great that recently the State Board of Medical Examiners couldn’t process all the new medical-license applications quickly enough. The board faced a backlog of 3,000 applications. To handle the extra workload, the legislature rushed through an emergency appropriation last year.

Now many of the newly arriving doctors are heading to rural or underserved parts of the state. Four new anesthesiologists have headed to Beaumont, for example. Meanwhile, San Antonio has experienced a 52% growth in the number of new doctors.

But if tort reform has been a boon – and it is likely one of the reasons the state’s economy has thrived in recent years – it was not easy to enact.

In one particularly grueling fight in the legislature in 2003, an important piece of a reform bill went down to a narrow defeat in the state Senate after a single Republican switched his support to vote against it. Republican Gov. Rick Perry was so incensed that he bolted out of his office in the Capitol, sprinted into the Senate chamber, and vaulted a railing to come face to face with the defecting senator.

That confrontation fizzled, however, and before long Texas succeeded at enacting two simple but effective reforms. One capped medical malpractice awards for noneconomic damages at $250,000, changed the burden of proof for claiming injury for emergency room care from simple negligence to “willful and wanton neglect,” and required that an independent medical expert file a report in support of the claimant.

This has allowed doctors and hospitals to cut costs and even increase the resources devoted to charity care. Take Christus Health, a nonprofit Catholic health system across the state. Thanks to tort reform, over the past four years Christus saved $100 million that it otherwise would have spent fending off bogus lawsuits or paying higher insurance premiums. Every dollar saved was reinvested in helping poor patients.

The second 2003 reform cleaned up much of the mess surrounding asbestos litigation by creating something called multidistrict litigation (MDL). This took every case in the state involving a common injury or complaint, like silicosis or asbestosis, and consolidated it for pretrial discovery in one court.

One judge now makes all pretrial discovery and evidence rulings, including the validity of expert doctor reports, for all cases. This creates legal consistency and virtually eliminates “venue shopping” – a process by which trial lawyers file briefs in districts that they know will be friendly to frivolous suits. Trials still occur in plaintiffs’ home counties.

More change sailed through the legislature in 2005; tort reform had become popular with voters and lobbying against it was ineffectual. The 2005 reform created minimum medical standards to prove an injury in asbestos and silica cases. Now plaintiffs must show diminished lung capacity in addition to an X-ray indicating disease.

In sum, these reforms have worked wonders. There are about 85,000 asbestos plaintiffs in Texas. Under the old system, each would be advancing in the courts. But in the four years since the creation of MDLs, only 300 plaintiffs’ cases have been certified ready for trial. And in each case the plaintiff is almost certainly sick with mesothelioma or cancer.

No one else claiming “asbestosis” has yet filed a pulmonology report showing diminished lung capacity. This means that only one-third of 1% of all those people who have filed suit claiming they were sick with asbestosis have actually had a qualified and impartial doctor agree that they have an asbestos-caused illness.

In the silica MDL, there are somewhere between 4,000 and 6,000 plaintiff cases. In the four years since the cases were consolidated under the MDL, 47 plaintiffs have filed a motion to proceed to trial based on a medical report indicating diminished pulmonary capacity. Of those 47, the court has certified 29 people as having diminished lung capacity. This, too, is less than 1% of all the “silicosis” claims made in Texas. No one has proven the real cause of his illness to be silica, as no case yet has been certified for trial.

Before the asbestos and silica MDLs were created, nonmalignancy plaintiffs settled with defendants for anywhere between $30,000 to $150,000 per case. No one knows how many bogus cases were settled in the state with large cash payments. Lawyers who specialized in defending those cases say there were tens of thousands.

The full costs of large settlements and runaway malpractice suits may never be known. But it is clear that the costs were paid for by consumers through the increased price of goods, by pensioners through diminished stock prices, and by workers through lost jobs. Another group often overlooked is those who are priced out of health care, or who didn’t receive charity care because doctors were squeezed by tort lawyers. Frivolous lawsuits hit the uninsured the hardest.

Texas recently became home to more Fortune 500 companies than New York and California. Things are trending well for the Lone Star State. Anecdotally, we can see that while doctors are moving in, trial lawyers are packing up and heading west. They’re GTC — Gone to California.

With house prices falling and the cost of gasoline and food rising, many nurses are going back to work, in some cases to make up for the income of a spouse who has lost a job. Hospitals say part-time nurses are taking on extra shifts. And nursing schools are seeing an increase in people applying for refresher courses on the ins and outs of modern hospitals. Some older nurses are putting off a planned retirement.

“We are seeing a temporary lessening of the nursing shortage,” says Jane Llewellyn, vice president of clinical nursing affairs at Rush University Medical Center in Chicago. But, she says, “as soon as the economy turns up we’ll see them staying home again.”

It’s a familiar pattern during economic slowdowns. For years, the high demand for nurses has allowed them to design work schedules that suit their financial and family needs. Many start off working full time on difficult shifts and then reduce their hours when they have a family — the profession is more than 90% female — or as they approach retirement. But when the economy goes sour, many nurses go back to work full time.

Dana Goodin, a nurse at Chicago’s Rush University, worked three evening shifts a week for nearly two decades, giving her time to raise her four children. But after her husband, a carpenter, was laid off late last year, Ms. Goodin began working four days a week to boost the family’s income and to qualify for cheaper health benefits. Although her husband has since found a new job at a retail warehouse, he makes just half of his former salary, and Ms. Goodin is looking for another shift to push her above full time.

The nursing profession also is attracting greater interest among new recruits, drawn by expanding job opportunities and rising wages in some places. Nursing school enrollment surged in the wake of the Sept. 11, 2001, terrorist attacks and the economic slowdown that followed. Enrollment continues to grow apace, though at a reduced rate, and schools are turning away thousands of qualified applicants for lack of faculty. Even so, nursing experts predict shortages will grow in future years as demand for nursing services outpaces the number of professionals entering the field.

For hospitals, the renewed interest in nursing is a relief. Shawn Tyrrell, chief nursing officer at Rush-Copley Medical Center in Aurora, Ill., says that until last year the hospital used outside employment agencies when it didn’t have enough nurses to cover the shifts. Now, despite an increase in patient volume, the hospital’s own nurses want extra hours, so it doesn’t need the agencies. “We’ve been able to handle that volume increase through our own staff members,” she says.

The nursing shortage began in the 1990s as older nurses started retiring and there were fewer newcomers to take their place. The crunch got worse as baby boomers got older and demand for health care increased. By 2001, there were 126,000 vacant nursing positions in the U.S., according to the American Hospital Association. That means about 13% of all nursing jobs were unfilled.

Beefing Up Recruiting

ON THE JOB

The economic slowdown is one factor helping temporarily to ease the nursing shortage.

• Many nurses are returning to the profession, or seeking more hours, after a spouse loses a job.

• Nurses who have been out of the profession often require refresher courses before returning to work.

• With more nurses available, some hospitals are finding it easier to schedule shifts.

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To attract nurses, hospitals have increased wages and beefed up recruiting, including from overseas, and have offered potential hires signing bonuses of cash or even new cars. Hospitals have also taken steps to keep older nurses in the work force by making their jobs easier, including replacing hand cranks used to lift beds with automated lift devices, bringing in lift teams so nurses don’t strain themselves picking up patients, or putting supplies closer to patients’ rooms to cut down on walking. By the end of 2006, the nurse vacancy rate had fallen to 8.1%.

Of course, nurses who haven’t been working for some time can’t just jump back into the job. Nurse-education requirements vary from state to state, but in general the longer the nurse has been out of the work force the more likely it is he or she will have to complete a refresher course to be relicensed. The Mount Carmel College of Nursing in Columbus, Ohio, for instance, offers a refresher program for $700 plus the cost of textbooks that includes 230 hours of online courses, covering such topics as anatomy, new medications and privacy regulations. Students also log 100 hours working in a clinical setting such as a nursing home or a hospital.

Economic Indicator

For the past few decades, nursing has been a kind of reverse economic indicator. In periods of economic weakness or recession — including in the early 1980s, the early 1990s and earlier this decade following the technology-company bust and the Sept. 11 attacks — the number of full-time nurses grew at an average annual rate of 3.5%. By contrast, in times of healthy economic expansion, the increase has averaged just 2.4%, according to an analysis of government data in “The Future of the Nursing Workforce in the U.S.,” a book by Peter Buerhaus, director of the Center for Interdisciplinary Health Workforce Studies at Vanderbilt University Medical Center, Douglas Staiger, a Dartmouth College economics professor, and David Auerbach, a principal analyst in the Health and Human Resources Division of the Congressional Budget Office.

Last year, there was a net increase of about 113,000 nurses in the work force, the largest increase since 2002, and most of the added nurses were over 50 years old, according to the Census Bureau. The pattern has continued this year. Although the U.S. economy lost 20,000 jobs in April, the fourth monthly decline in a row, health-care employment rose by 37,000 and is up 365,000 jobs over the past 12 months, according to Labor Department data released last week.

“In bust periods, unemployment is rising, which means there is a lot of pressure on married RNs to be working,” says Mr. Buerhaus.

Jennifer Schlesser, a 57-year-old Ellicott City, Md., resident, says she worked as a nurse for 27 years before leaving the profession a decade ago, feeling overworked and underpaid. She went to work in the mortgage-lending industry, but the housing slowdown has forced her to change employers and has cut into her commissions.

Refresher Courses

Ms. Schlesser is currently enrolled in an online refresher course for nursing and she expects to be relicensed by next month. She plans to work part time in both nursing and mortgage lending. “Whatever works out best,” she says.

But over the long term the nursing shortage is expected to continue and eventually worsen, as retiring baby boomers ramp up demand for care. In their book, Messrs. Buerhaus, Staiger and Auerbach use Census data to project that the nursing work force will plateau in 2015. By 2025, they estimate there will be a shortage of almost 500,000 nurses, representing a vacancy rate of 40% or higher.