FOLK MEDICINE

TRADITIONAL MEDICINE , ANCIENT MEDICINE

1. Folk medicine practices in India 2 nd yera Dr. Suresh Chand Yaddanapalli post graduate Department of Public Health Dentistry 1

2. contents Introduction Tribal medicine Traditional medicine – Indian context Classification of Traditional medicine 2

3. Classical stream/Great traditional medicine Folk stream/ Little traditional medicine Importance of traditional medicinal plants Medicinal plants and their use towards oral health care by various Indian Tribal population 3

4. Public Health Significance Policy implications References 4

5. introduction 80 % of the population of developing countries rely on traditional medicine mostly plant drugs, for their primary health care needs. (WHO) Natural Non-narcotic No side effects 5

6. 705 tribal communities 227 ethnic groups 5000 villages Tropical zone Forests of Western and Eastern Ghats Tribal medicinal knowledge - new drugs in modern medicine 6

7. So the study about the tribal medicine assumes much relevance in the context of the 'health for all' concept of the WHO. Modern allopathic medicines Ever-increasing price Dangerous side effects S cientific validations of many tribal knowledge of medicine Greater awareness in India towards tribal medicines 7

8. WHO Traditional Medicine Strategy 2002-2005 Policy: integrate TM/ CAM(complementary and alternative medicine) with national health care systems Safety, efficacy and quality: provide guidance and support for effective regulation Access: ensure availability and affordability of TM/CAM Rational use: promote therapeutically-sound use of TM/CAM by providers and consumers 8

9. Tribal medicine Tribal medicine can be considered as a part of the traditional medicine, which is mainly practiced by the tribals settled in the forest area M ainly confined to the medicinal plants available from the forest 9

10. Definition A tribal medicine or folk system of medicine is a set of dynamic medicinal practices, based on the principles of trial and error, and on empirical evidence, which has evolved over a period of time within a unique socio-cultural and physical- environment ( Johari and Karki , Tribal folk medicinal plant resources of south Asia, 1999 ) 10

11. Definitions based on various dictionaries: 1) Health practices arising from superstition, cultural traditions, or empirical use of native remedies, especially food substances. ( Dictionary.com ) 2) Traditional medicine as practiced by nonprofessional healers or embodied in local custom or lore, generally involving the use of natural and especially herbal remedies. (The American Heritage® Stedman's Medical Dictionary) 3) Traditional medicine that is based especially on the use of plants instead of modern scientific principles ( cambridge dictionary) 11

12. Traditional medicine Traditional medicine has been prevalent in every country since the beginning of the civilization. According to Siegerist (1951), a medical historian "every culture had developed a system of their own medicine and medical history is one aspect of the history of culture " 12

13. The term "traditional medicine" refers to ways of protecting and restoring health that existed before the arrival of modern medicine . Not all health practices are health traditions 13

14. T raditions are those practices that are self-perpetuating. T hey form the unwritten repertory of health practices that have been passed down the generations through word of mouth for at least one century and continue to be passed down even today Shankar et al, 2001 14

15. definition "The sum total of all the knowledge and practices, used in diagnosis, prevention and elimination of physical, mental or social imbalance and relying exclusively on practical experience and observation handed down from generation to generation, whether verbally or in writing" WHO , 1978 15

16. Traditional medicine (TM). A ccording to WHO definition adopted in 2000, traditional medicine is “the sum total of the knowledge, skills and practices based on the theories, beliefs and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health, as well as in the prevention, diagnosis, improvement or treatment of physical and mental illnesses .”. 16

17. According to WHO definition adopted in 2003, traditional medicine refers to health practices, approaches, knowledge and beliefs incorporating plant, animal and mineral based medicines, spiritual therapies, manual techniques and exercises, applied singularly or in combination to treat, diagnose and prevent illnesses or maintain well- being. 17

18. Traditional Healers: Some one who is recognised by the community in which he lives as competent to provide health care by using vegetable, animal & mineral substances and certain other methods based on the social, cultural and religious backgrounds as well as prevailing knowledge, attitudes and beliefs regarding physical, mental and social well being and the causation of disease and disability in the community. 18 Ramashankar et al (2015) Traditional healing practices in north east India; journal of history of science,50(2),324-332.

19. INDIAN CONTEXT 2000 B.C. – disease - wrath of gods and effect of evil spirits H ealing art - prayers , several hymns and often aided by the herbal remedies In course of time the science of medicine, which came to be known as Ayurveda was formed. 19

20. . Rigveda , which is considered to be the oldest available record in India, dating back to 4000-5000 B.C. recounts some medicinal plants. Atharvaveda , another religious book of Hindus, has described about 2000 plants having medicinal properties Charaka and Susruta (700 B.C) contributed to popularise the Ayurveda in India by bringing out Sanskrit medical manuals namely, the Charaka Samhita and Susruta Samhita respectively. 20

21. A hospital in the true sense of the term is clearly described by Fahsien , the Chinese traveller who visited India at the very beginning of the 5 th century AD. Soon other systems of medicines like Sidha and Unani also emerged and continued to develop with Ayurveda. 21

22. Medicinal plants are nature’s gift to mankind and are rich heritage of India. India is well known as an “Emporium of medicinal plants”. About 70% of the rural folk depend on medicinal plants for their health care. India is a treasure of biodiversity which host a large variety of plants and ranks tenth among plant rich countries of the world and fourth among the Asian countries. 22

23. India is considered as one of the 12 mega-biodiversity countries of the world having rich vegetation of about 45,000 vascular plants, with concentrated hotspots in the regions of Eastern Himalayas, Western Ghats and Andaman & Nicobar Islands. Of these, the folk medicine system of India use about 5,000 plant species with about 25,000 formulations for treating a variety of ailments, whereas the tribal medicine involves the use of over 8,000 wild plants with about 1,75,000 specific preparations/applications. The classical indigenous systems of Indian medicine prescribe 10,000 designated formulations. 23

24. Classification of traditional medicine Traditional medicine Little traditional medicine/folk streams Great traditional medicine/classical streams Folk medicine Or Ethno medicine Or Tribal medicine Ayurveda Unani Sidha Naturopathy Yoga Homeopathy Task Force Report, Government of India (2000) 24

25. Classical Stream Ayurvedic Medicine Ayurveda tends to focus on the use of single herbs for most symptoms. Ayurveda is based on theories more closely related to the Greco-Roman concept of the four humors - blood, phelgm (mucous secretion), yellow bile and black bile than to the Chinese concept of yin and yang. 25

26. The Ayurvedic forces are the three doshas - Kapha (cold, moist), pitta (hot, dry) and vata (wind). These tridoshas interact with the gunas (basic psychological qualities of the mind) and other characteristic that are perceived to be relevant factors that govern life and health . Aggarwal , 1998 26

27. Ayurveda and orofacial diseases According to the Shalyatantra and Shalakyatantra (one of the branches of Ayurveda), 65 varieties of oral diseases can arise in seven anatomic locations-eight on the lips, 15 on the alveolar margin, eight in connection with the teeth, five on the tongue, nine on the palate, 17 in the oropharynx and three in a generalized form. O ral cleansing, extractions, excisions, flap surgeries Chakravorty RC. Head and neck diseases in an ancient Indian surgical text (The Sushruta-samhita ) Med Hist. 1971;15:393–6 . 27

28. Along with the treatment of orofacial diseases, Ayurveda recommends some daily use therapeutic procedures for the prevention and maintenance of oral health. These include: Dant Dhavani (Brushing), Jivha Lekhana (Tongue scrapping) and Gandoosha (gargling) or oil pulling and tissue regeneration therapies. 28

29. Dant Dhavani (brushing): Avurveda recommends chewing sticks in the morning as well as after every meal to prevent diseases. The neem ( margosa or Azadirachta indica ) is a famous herbal chewing stick. Fresh stems of liquorice ( Glycyrrhiza glabra ), black catechu or the cutch tree (Acacia Catechu Linn .), Arjuna tree ( Termmalia arjuna ), can also be used for brushing. 29

30. Chewing on these stems is believed to cause attrition and leveling of biting surfaces, facilitate salivary secretion and possibly, help in plaque control while some stems have an anti-bacterial action. Present-day research has shown that all the chewing sticks described in ancient Ayurveda texts have medicinal and anti-cariogenic properties Telles S, Naveen KV, Balkrishna A. Use of Ayurveda in promoting dental health and preventing dental caries. Indian J Dent Res. 2009;20:246. 30

31. Jivha Lekhana (tongue scrapping): It is ideal to use gold, silver, copper, stainless steel for the scrapping of the tongue. Tongue scrapping stimulates the reflex points of the tongue, removes bad odor and improves the sense of taste. Clinical evidence also shows that use of tongue scrapers on a regular basis, has a significant improvement on eliminating anaerobic bacteria and decreases bad odor . Kadam A, Prasad BS, Bagadia D, Hiremath VR. Effect of Ayurvedic herbs on control of plaque and gingivitis: A randomized controlled trial. Ayu . 2011;32:532–5 . 31

32. Gandusha (gargling) or oil pulling: Oil pulling is an ancient Ayurveda procedure that involves swishing oil in the mouth for oral and systemic health benefits . It is mentioned in the Avurvedic text Charaka Samhita where it is called Kavala or Gandusha and is claimed to cure about 30 systemic diseases ranging from headache, migraine to diabetes and asthma. Oil pulling therapy can be done using oils like sunflower oil or sesame oil . 32

33. Tissue regeneration therapies: In Avurveda , the well-known herb, Amla ( Phyllanthus emblica ) is considered a general rebuilder of oral health. One to two grams per day can be taken orally in capsules for the long-term benefit to the teeth and gums. Amla supports the healing and development of connective tissue when taken internally . Singh A, Purohit B. Tooth brushing, oil pulling and tissue regeneration: A review of holistic approaches to oral health. J Ayurveda Integr Med. 2011;2:64–8. 33

34. UNANi medicine Unani- tibb or Unani Medicine also spelled Yunani Medicine (in Arabic, Hindi-Urdu and Persian) means “Greek Medicine.” Its origin is traced back to the Greek literature, which has been a source of quite a lot of scientific contributions and also was developed by Arabs and Persians into an elaborate medical science. Since that time Unani Medicine has been known as Greco-Arab Medicine 34

35. The World Health Organization (WHO) has recognized the Unani System of Medicine (USM) as an alternative system to cater(serve) the health care needs of human population. Unani is one of the most well-known traditional medicine systems and draws on the ancient traditional systems of medicine of China, Egypt, India, Iraq, Persia and Syria Unani Medicine in India. Its Origin and Fundamental Concepts by Hakim Syed Zillur Rahman, History of Science, Philosophy and Culture in Indian Civilization, Vol. IV Part 2 (Medicine and Life Sciences in India), Ed. B. V. Subbarayappa , Centre for Studies in Civilizations, Project of History of Indian Science. Philosophy and Culture, New Delhi. 2001:298–325 . 35

36. UNANI and orofacial diseases Unani formulations like Sunune Zard , Sunune Mulook , Buzidan , Majoon Suranjan , Majoon Azaraqi , Habbe Gule Aak etc. have been shown effective anti-bacterial , anti-inflammatory and analgesic effect and are used in the treatment of orofacial diseases Hongal , S., Torwane , N. A., Pankaj, G., Chandrashekhar , B. ., & Gouraha , A. (2014). Role of Unani System of Medicine in Management of Orofacial Diseases: A Review. Journal of Clinical and Diagnostic Research : JCDR , 8 (10),12–15. 36

37. Siddha medicine Siddha medicine emerged 2000 years ago from south-eastern state of India, Tamil Nadu. The name Siddha signifies Siddhi which symbolizes an attainment in life arts such as yoga, wisdom, philosophy, medicine and above all the art of longevity. The individual, who acquired this Siddhi, were courteously called Siddhars . Narayanaswamy V. Ayurveda and Siddha system of medicine- A comparative study. Subramanian S.V. and Madhaven V.R., ( Eds ), Heritage of Tamil Siddha medicine. International Institute of Tamil Studies, Madras, India, 1983; 568-576. 37

38. Agasthiyar , one among the 18 Siddhars ; is believed to be ‘Hippocrates of Siddha medicine’. Siddhars are the spiritual scientists of Tamil Nadu who reviewed and unfold the reality of nature and its association to man by their yogic awareness and experimental discoveries furthermore; they hypothesized the idea of spiritualism for self-improvement . Sampath C.K. () Evolution and development of Siddha medicine. Subramania S.V. and Madhaven V.R. ( Eds ), Heritage of Tamil Siddha medicine. International Institute of Tamil Studies, Madras, India, 1983; 1-20. 38

39. Siddha and orofacial diseases In Siddha system of medicine, a total of 108 herbs, collectively known as karpa mooligaigal are dominantly used for the human ailments including management of oral disorders. Most of the herbs prescribed in Siddha, possess anti plaque, cariogenic, antibacterial, anti-inflammatory , analgesic, antitumor, anti-stress, anti-fungal, rapid healing properties . Borchers AT. Traditional Asian medicine and oral health. J Tradit Med., 2004; 21: 17-26 . 39

40. Naturopathy and yoga medicine This could be taken as integration of folk medicine and ayurvedic medicine. The concept was popularised by Gandhiji through personal experiences and observance with natural cures. This system of health care includes indigenous medicine, dietary regulation and yogic exercise relating to the specific areas of bodies as well as external application like mud bath, sunbath, body massage as well as exercise on mental concentration. 40

41. Homeopathy The system is originated in Germany and later practiced and developed in Asia and European countries. The concept of this medicine is of creating a resistance to an illness by administering small doses of specially grounded medicines in biological ritualism 41

42. Homeopathic medicine in oral health Mouthwash of Salvia infusions was given several times a day to diminish pain of “dry socket” and a few drops of hypercal ( Hypericum and Clandedula tinctures) was also given, in a small glass of warm water to relieve dryness and make mouth much more comfortable. ORAL HERPES LESIONS: Patients with oral herpes lesions could be given Graphites , Petroleum, Rhus toxicodendron and Arsenicum album and the lesions resolve early with minimum discomfort to patients . Homeopathy in Dentistry – An Overview, International Contemporary Dental Journal, March 2011 2 (2). 42

43. SEVERE GINGIVITIS: Arsenicum album and Ferrum phosphoricum were given to the patient who reported with severe gingivitis. PAIN: Chamomilla , one hour prior to surgery, and repeated every 15 minutes BRUXISM : Patients were given cina one hour before sleep and while awake nux vomica twice daily till the symptoms subside 43

44. Tribal medicine/folk medicine/ethno medicine The tribes who lives in isolation, practices their own system of medicine, which is known as tribal medicine or ethno medicine. The tribal population of the country, as per 2011 census, is 10.43 crore, constituting 8.6% of the total population. 89.97 % of them live in rural areas and 10.03% in urban areas. 44

45. Andhra Pradesh has 27,39,919 tribal population as per 2011 census which constitutes 5.53% of the total population. District Wise Population of Scheduled Tribes of A.P. 2011 census, www.aptribes.gov.in; accessed on 13 th may 2017. 45

46. Andhra pradesh Ayurveda hospitals: 3 Unani : 2 Homeopathy: 3 Total allopathy hospitals: 270 Total p hc’s: 1155( as of march 2017) 46

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48. The use of medicinal plants for the treatment of disease was known to the tribals many centuries ago. From time immemorial the people especially tribal people realized the curing and healing properties of the herbs and roots (Sharma, 1999). There are estimated to be around 25,000 effective plant based formulations used in folk medicine and known to rural communities all over India. Planning Commission of India, 2000 48

49. Different tribal communities utilize different plants or different parts of the same plants for particular ailments . This indicates a deep knowledge about these herbs and plant as well as combination and dose of such indigenous objects for cure of different diseases ( Chaudhari , 1989). 49

50. A survey conducted by the All India co-ordinated Research project on Ethnobiology (AICRPE) recorded over 8000 species of wild plants used by the tribals and other traditional communities in India for treating various health problems (ISMH, 2001). The maximum numbers of medicinal plants are utilized by the folk traditions, followed by Ayurveda, Sidha , Unani, Homeopathy, Tibetan and Modern respectively (Shankar et al, 2000). 50

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52. Medicinal plants and their use towards oral health care by various I ndian tribal population 52

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59. FOLK TREATMENTS: Bee Stings a) Ice is put on the sting. If ice is not available, the wound is washed with cold water or mud is smeared on it. b) A bunch of parsley is wrapped around the affected area. c) The victim rubs garlic on the sting. High Temperatures a) A towel is moistened with vinegar and pressed onto the brow, neck, hands, feet and the whole body. This operation is repeated untill the patient’s temperature gone down. b) An aspirin is dissolved in lemon juice and rubbed on the patient’s body, beginning with the forehead. c) A mixture of grain alcohol, aspirin and few drops of olive oil is rubbed on the articular parts of the body. Asthma A pigeon egg is consumed every morning for 40 days as the first meal of the day. Aches a) The leaf of a black cabbage is heated and placed on the affected area. This operation is repeated frequently. b) A mixture of boiled and mashed linen seeds, henna and naphtha oil is rubbed on aching parts of the body. This operation continues a few times a day. c) A cream is made from dry tobacco and raki . The affected areas covered with this cream. d) Thin sand is roasted, a few olives are added and the affected areas are covered with this mixture while it is still warm or hot. This operation goes on for three or four days. Sore Feet Unrefined salt is dissolved in hot water, and the feet are washed in this solution for ten minutes. Sprains An onion is mashed with either salt or olives and placed on the sprained area 59

60. Headaches: a) A potato is cut into slices and coffee sprinkled on them. These slices are placed on the forehead. b) Round lemon slices are placed on the forehead. c) The patient covers his head with the gall of an animal, mixed with henna, for a few hours. Bronchitis: a) Linen seeds are mashed with sugar and eaten. b) A piece of bread is roasted, moistened with vinegar and placed on the chest. Tonsilitis The throat is covered with a piece of cotton with pepper and grain alcohol. Kidney Stones : a) Medlar leaves are boiled and drunk as tea. This continues until the stone is ejected. b) Water with parsley or yogurt is drunk every morning. Nosebleeds : The shell of an egg is burned till it becomes ash. The victims breaths in this ash when his or her nose starts to bleed. Haemorrhoids : a) Garlic is rubbed on every morning. b) The middle parts of wild roses are boiled and drunk as tea. 60

61. Eczema a) Eggplant is cooked in hot ashes and mixed with powdered henna. The ointment is placed on the affected area and covered with a clean towel. b) Peach leaves are boiled and drunk as tea for ten days. c) The patient eats hedgehog meat. d) The patient swallows the seeds of the elderberry plant . Shortness of Breath a) Stingling nettle tea is drunk every day. b) Black radish is hollowed out and filled with honey. A small hole is opened in the radish and a cup put under it. The patient eats the honey that flows out a!er waiting for a night. c) Cones are boiled and drunk as tea . Coughs a) The patient drinks a spoonful of honey mixed with a spoonful of lemon juice every morning for a few days. b) Apple and lemon peel and linden flowers are together boiled and drunk every morning. c) The patient eats raw parsley . Heat Rash Dry cat tail is heated and the ashes rubbed onto the affected parts of the body. 61

62. Public health significance Folk healers continue to play a key public health role contributing to availability of human resources in countries where the population to physician ratio is high. Traditional medicine is one of the surest means to achieve' total health care coverage of the whole population using acceptable safe, economically feasible method 62

63. The advantages of traditional medicine include its diversity, flexibility, availability and affordability in many parts of the world; its widespread acceptance in low- and middle- income countries; its comparatively low cost; and the relatively low level of technological input required . As a result, traditional medicinal therapies have the potential to contribute to a better health care system in many countries. 63

64. Policy implications India is blessed with rare species of medicinal plants possessing effective curative value and a number of tribal practitioners having valuable medicinal knowledge about these plants . If these natural resources are properly utilised and projected at global level with adequate legal framework to protect Intellectual Property Right (IPR) issues, India can make tremendous development. 64

65. While making tribal medicine a tool for development, the Government must recognise the cultural, intellectual and commercial importance of tribal medicine. Government should safeguard the cultural heritage and background of the tribals and tribal medicine. 65

66. Government should also enact proper legislation to protect the intellectual property right of the tribals. Government should tap the commercial potentiality of the trading of medicinal plants and the tourism aspects of the tribal surroundings. 66

67. Appropriate health policy has to be formulated to integrate tribal medicine with modern medicine. On a broader plane, it could be said that the government has given all its patronage to the spread of Allopathic system of medicine. This approach has to be changed. 67

68. 68 Advantages: Reduced the risk of side effects Effective with chronic conditions Lower cost Widespread availability Disadvantages: Inappropriate for many conditions(Modern medicine treats sudden and serious illness and accidents) Lack of dosage instructions Poison risk associated with wild herbs Medication interactions Lack of regulation(The quality of the herbs may vary)

69. The dentist needs to be more informed regarding the use, safety and effectiveness of the various traditional medicines. As this is hardly explored part for the field of dentistry, there is a need for integration of professional dental treatment modalities and complementary alternative medical systems to provide the best and unique from each system to patients as a complementary therapy and an alternative choice of treatment Conclusion : 69

70. References Aggarwal, K. K. (1998). Eastern medicine: In its entirety - IJCP's Medinews , December. Anilkumar , N. and Vedavalli , L. (1999) The ecosystem people and conservation of medicinal plants: a case study from the Siruvani hills, Tarnilnadu - In Tribal folk medicinal plant resources of south Asia/Ed. by Radhika Johari and Madhav Karki - Canada: IDRC. Kutumbaih , P. (1962). Ancient Indian Medicine - Madras: Orient Longmans. Lambert, John et a1 (1997). Medicinal Plants: rescuing a global heritage - Washington: World Bank. Lanfranco G. (1992). Popular use of medicinal plants in the Maltese islands - Insula, No. 1,pp.34-35. Ling, S. K. (1998). Medicinal plants used for treating female diseases in Malaysia: a review - American Journal of Chinese Medicine, Vol. 26(2),pp. 211-222. 70

71. Planning Commission - Government of India (2000). Report of the Task force on conservation and sustainable use of medicinal plants: http:/ / planningcommission.nic.int /ask/ tsk- medi.pdf . Reddy, B. Sanjeev, (1986). An approach to the integration of traditional medicine and modern medicine: a hypothetical model - In Tribal health/Ed. by Buddhadeb Chaudhari - New Delhi: Inter India Sieggerist , Henry (1951). A history of medicine. Vol. 1, London: Oxford University Press WHO (1978). The promotion and development of traditional medicine - Technical report series, 622 - Geneva: WHO. Badgujar SB, Mahajan RT, Kosalge SB. Traditional Practice for Oral Health Care in Nandurbar District of Maharashtra. India Ethnobot Leaflets 2008; 12:1137-44. 
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72. Meena KL, Yadav BL. Some ethnomedicinal plants of Rajasthan. Indian j of traditional knowledge 2010; 9(1)169-172. Achuta NS, Sharad S, Rawat AKS. An ethnobotanical study of medicinal plants of Rewa districts. Madhya Pradesh. Indian journal of traditional knowledge 2010; 9(1):191-202. 
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73. Akilesh KTDD, Tewari JP. Etnomedicinal knowledge among Tharu tribe of Devipatan division. Indian journal of traditional knowledge 2006; 5(3):310-313. 
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74. 21) World Health Organization. General Guidelines for Methodologies on Research and Evaluation of Traditional Medicine. Geneva: World Health Organization, 2000. A vailable from URL: http:// whqlibdoc.who.int / hq /2000/WHO_EDM_TRM_2000.1.pdf (Accessed: may 15, 2017). 22) World Health Organization. Traditional medicine. Fact sheet N°134. Geneva: W orld Health Organization, 2003. A vailable from URL: http:// www.who.int / mediacentre /factsheets/fs134/en/ print.html (Accessed: may 15, 2017). 23) Ramashankar et al (2015) Traditional healing practices in north east India; journal of history of science,50(2),324-332. 74

75. Thank you 75

76. ` Effect of Ayurvedic herbs on control of plaque and gingivitis: A randomized controlled trial. Kadam A1, et al.( 2011) Present study was conducted for evaluating the effect of one of such Ayurvedic toothpowder named UDM, in controlling plaque and reducing gum inflammation in patients of moderate gingivitis. Scaling, root planning, and polishing were done for all the patients participating in the study. Oral hygiene instructions were given that included brushing twice/day with assigned tooth powder using BASS method for tooth brushing and also massage over gum tissue with finger. All the patients were recalled after 15 days. Scores of plaque index and gingival index was recorded on day 1 and day 15 of treatment. Total of 15 patients were recruited in each group. The mean reduction in gingival index was 1.15 (P<0.05) and 1.26 (P<0.05) in positive control and UDM treatment groups, respectively. However, the mean reduction in plaque indices were found to be 2.03 (P<0.05) and 2.16 (P<0.05) in positive control and UDM groups, respectively. No significant difference was seen in both the parameters between the two groups. 76