Cherokee Indians Holistic Plants and Roots Used to Cure Sickness

ABOUT CHEROKEE INDIANS HOLISTIC SELECTED LIST OF PLANTS USED TO CURE SICKNESS

1. UNASTE´TSTIYÛ=“very small root”—Aristolochia serpentaria—Virginia or black snakeroot: Decoction of root blown upon patient for fever and feverish headache, and drunk for coughs; root chewed and spit upon wound to cure snake bites; bruised root placed in hollow tooth for toothache, and held against nose made sore by constant blowing in colds. Dispensatory: “A stimulant tonic, acting also as a diaphoretic or diuretic, according to the mode of its application; * * * also been highly recommended in intermittent fevers, and though itself generally inadequate to the cure often proves serviceable as an adjunct to Peruvian bark or sulphate of quinia.” Also used for typhous diseases, in dyspepsia, as a gargle for sore throat, as a mild stimulant in typhoid fevers, and to promote eruptions. The genus derives its scientific name from its supposed efficacy in promoting menstrual discharge, and some species have acquired the “reputation of antidotes for the bites of serpents.”

2. UNISTIL´ÛⁿISTÎ⁸=“they stick on”—Cynoglossum Morrisoni—Beggar lice: Decoction of root or top drunk for kidney troubles; bruised root used with bear oil as an ointment for cancer; forgetful persons drink a decoction of this plant, and probably also of other similar bur plants, from an idea that the sticking qualities of the burs will thus be imparted to the memory. From a similar connection of ideas the root is also used in the preparation of love charms. Dispensatory: Not named. C. officinale “has been used as a demulcent and sedative in coughs, catarrh, spitting of blood, dysentery, and diarrhea, and has been also applied externally in burns, ulcers, scrofulous tumors and goiter.”

[pg 325]

3. ÛⁿNAGÉI=“black”—Cassia Marilandica—Wild senna: Root bruised and moistened with water for poulticing sores; decoction drunk for fever and for a disease also called ûⁿnage´i, or “black” (same name as plant), in which the hands and eye sockets are said to turn black; also for a disease described as similar to ûⁿnagei, but more dangerous, in which the eye sockets become black, while black spots appear on the arms, legs, and over the ribs on one side of the body, accompanied by partial paralysis, and resulting in death should the black spots appear also on the other side. Dispensatory: Described as “an efficient and safe cathartic, * * * most conveniently given in the form of infusion.”

4. KÂSD´ÚTA=“simulating ashes,” so called on account of the appearance of the leaves—Gnaphalium decurrens—Life everlasting: Decoction drunk for colds; also used in the sweat bath for various diseases and considered one of their most valuable medical plants. Dispensatory: Not named. Decoctions of two other species of this genus are mentioned as used by country people for chest and bowel diseases, and for hemorrhages, bruises, ulcers, etc., although “probably possessing little medicinal virtue.”

5. ALTSA´STI=“a wreath for the head”—Vicia Caroliniana—Vetch: Decoction drunk for dyspepsia and pains in the back, and rubbed on stomach for cramp; also rubbed on ball-players after scratching, to render their muscles tough, and used in the same way after scratching in the disease referred to under ûⁿnagei, in which one side becomes black in spots, with partial paralysis; also used in same manner in decoction with Kâsduta for rheumatism; considered one of their most valuable medicinal herbs. Dispensatory: Not named.

6. DISTAI´YĬ=“they (the roots) are tough”—Tephrosia Virginiana—Catgut, Turkey Pea, Goat’s Rue, or Devil’s Shoestrings: Decoction drunk for lassitude. Women wash their hair in decoction of its roots to prevent its breaking or falling out, because these roots are very tough and hard to break; from the same idea ball-players rub the decoction on their limbs after scratching, to toughen them. Dispensatory: Described as a cathartic with roots tonic and aperient.

7. U´GA-ATASGI´SKĬ=“the pus oozes out”—Euphorbia hypericifolia—Milkweed: Juice rubbed on for skin eruptions, especially on children’s heads; also used as a purgative; decoction drunk for gonorrhœa and similar diseases in both sexes, and held in high estimation for this purpose; juice used as an ointment for sores and for sore nipples, and in connection with other herbs for cancer. Dispensatory: The juice of all of the genus has the property of “powerfully irritating the skin when applied to it,” while nearly all are powerful emetics and cathartics. This species “has been highly commended as a remedy in dysentery after due depletion, diarrhea, menorrhagia, and leucorrhea.”

8. GÛ´NĬGWALĬ´SKĬ=“It becomes discolored when bruised”—Scutellaria lateriflora—Skullcap. The name refers to the red juice which comes out of the stalk when bruised or chewed. A decoction of the four varieties of Gûnigwalĭ´skĭ—S. lateriflora, S. pilosa, Hypericum corymbosum, and Stylosanthes elatior—is drunk to promote menstruation, and the same decoction is also drunk and used as a wash to counteract the ill effects of eating food prepared by a woman in the menstrual condition, or when such a woman by chance comes into a sick room or a house under the tabu; also drunk for diarrhea and used with other herbs in decoction for breast pains. Dispensatory: This plant “produces no very obvious effects,” but some doctors regard it as possessed of nervine, antispasmodic and tonic properties. None of the other three species are named.

[pg 326]

9. K´GA SKÛⁿTAGĬ=“crow shin”—Adiantum pedatum—Maidenhair Fern: Used either in decoction or poultice for rheumatism and chills, generally in connection with some other fern. The doctors explain that the fronds of the different varieties of fern are curled up in the young plant, but unroll and straighten out as it grows, and consequently a decoction of ferns causes the contracted muscles of the rheumatic patient to unbend and straighten out in like manner. It is also used in decoction for fever. Dispensatory: The leaves “have been supposed to be useful in chronic catarrh and other pectoral affections.”

10. ANDA´NKALAGI´SKĬ=“it removes things from the gums”—Geranium maculatum—Wild Alum, Cranesbill: Used in decoction with Yânû Unihye´stĭ (Vitis cordifolia) to wash the mouths of children in thrush; also used alone for the same purpose by blowing the chewed fiber into the mouth. Dispensatory: “One of our best indigenous astringents. * * * Diarrhea, chronic dysentery, cholora infantum in the latter stages, and the various hemorrhages are the forms of disease in which it is most commonly used.” Also valuable as “an application to indolent ulcers, an injection in gleet and leucorrhea, a gargle in relaxation of the uvula and aphthous ulcerations of the throat.” The other plant sometimes used with it is not mentioned.

11. Û´ⁿLĔ UKĬ´LTĬ=“the locust frequents it”—Gillenia trifoliata—Indian Physic. Two doctors state that it is good as a tea for bowel complaints, with fever and yellow vomit; but another says that it is poisonous and that no decoction is ever drunk, but that the beaten root is a good poultice for swellings. Dispensatory: “Gillenia is a mild and efficient emetic, and like most substances belonging to the same class occasionally acts upon the bowels. In very small doses it has been thought to be tonic.”

12. SKWA´LĬ=Hepatica acutiloba—Liverwort, Heartleaf: Used for coughs either in tea or by chewing root. Those who dream of snakes drink a decoction of this herb and I´natû Ga´n‘ka=“snake tongue” (Camptosorus rhizophyllus or Walking Fern) to produce vomiting, after which the dreams do not return. The traders buy large quantities of liverwort from the Cherokees, who may thus have learned to esteem it more highly than they otherwise would. The appearance of the other plant, Camptosorus rhizophyllus, has evidently determined its Cherokee name and the use to which it is applied. Dispensatory: “Liverwort is a very mild demulcent tonic and astringent, supposed by some to possess diuretic and deobstruent virtues. It was formerly used in Europe in various complaints, especially chronic hepatic affections, but has fallen into entire neglect. In this country, some years since, it acquired considerable reputation, which, however, it has not maintained as a remedy in hæmoptysis and chronic coughs.” The other plant is not named.

13. DA´YEWÛ=“it sews itself up,” because the leaves are said to grow together again when torn—Cacalia atriplicifolia—Tassel Flower: Held in great repute as a poultice for cuts, bruises, and cancer, to draw out the blood or poisonous matter. The bruised leaf is bound over the spot and frequently removed. The dry powdered leaf was formerly used to sprinkle over food like salt. Dispensatory: Not named.

14. A´TALĬ KÛLĬ´=“it climbs the mountain.”—Aralia quinquefolia—Ginseng or “Sang:” Decoction of root drunk for headache, cramps, etc., and for female troubles; chewed root blown on spot for pains in the side. The Cherokees sell large quantities of sang to the traders for 50 cents per pound, nearly equivalent there to two days’ wages, a fact which has doubtless increased their idea of its importance. Dispensatory: “The extraordinary medical virtues formerly ascribed to ginseng had no other existence than in the imagination of the Chinese. It is little more than a demulcent, and in this [pg 327]country is not employed as a medicine.” The Chinese name, ginseng, is said to refer to the fancied resemblance of the root to a human figure, while in the Cherokee formulas it is addressed as the “great man” or “little man,” and this resemblance no doubt has much to do with the estimation in which it is held by both peoples.

15. ÛTSATĬ UWADSĬSKA=“fish scales,” from shape of leaves—Thalictrum anemonoides—Meadow Rue: Decoction of root drunk for diarrhea with vomiting. Dispensatory: Not named.

16. K´KWĔ ULASU´LA=“partridge moccasin”—Cypripedium parviflorum—Lady-slipper: Decoction of root used for worms in children. In the liquid are placed some stalks of the common chickweed or purslane (Cerastium vulgatum) which, from the appearance of its red fleshy stalks, is supposed to have some connection with worms. Dispensatory: Described as “a gentle nervous stimulant” useful in diseases in which the nerves are especially affected. The other herb is not named.

17. A´HAWĬ´ AKĂ´TĂ´=“deer eye,” from the appearance of the flower—Rudbeckia fulgida—Cone Flower: Decoction of root drunk for flux and for some private diseases; also used as a wash for snake bites and swellings caused by (mythic) tsgâya or worms; also dropped into weak or inflamed eyes. This last is probably from the supposed connection between the eye and the flower resembling the eye. Dispensatory: Not named.

18. UTĬSTUGĬ´=Polygonatum multiflorum latifolium—Solomon’s Seal: Root heated and bruised and applied as a poultice to remove an ulcerating swelling called tu´stĭ´, resembling a boil or carbuncle. Dispensatory: “This species acts like P. uniflorum, which is said to be emetic. In former times it was used externally in bruises, especially those about the eyes, in tumors, wounds, and cutaneous eruptions and was highly esteemed as a cosmetic. At present it is not employed, though recommended by Hermann as a good remedy in gout and rheumatism.” This species in decoction has been found to produce “nausea, a cathartic effect and either diaphoresis or diuresis,” and is useful “as an internal remedy in piles, and externally in the form of decoction, in the affection of the skin resulting from the poisonous exhalations of certain plants.”

19. ĂMĂDITA‘TÌ=“water dipper,” because water can be sucked up through its hollow stalk—Eupatorium purpureum—Queen of the Meadow, Gravel Root: Root used in decoction with a somewhat similar plant called Ămăditá´tĭ û´tanu, or “large water dipper” (not identified) for difficult urination. Dispensatory: “Said to operate as a diuretic. Its vulgar name of gravel root indicates the popular estimation of its virtues.” The genus is described as tonic, diaphoretic, and in large doses emetic and aperient.

20. YÂNA UTSĔSTA=“the bear lies on it”—Aspidium acrostichoides—Shield Fern: Root decoction drunk to produce vomiting, and also used to rub on the skin, after scratching, for rheumatism—in both cases some other plant is added to the decoction; the warm decoction is also held in the mouth to relieve toothache. Dispensatory: Not named.

The results obtained from a careful study of this list may be summarized as follows: Of the twenty plants described as used by the Cherokees, seven (Nos. 2, 4, 5, 13, 15, 17, and 20) are not noticed in the Dispensatory even in the list of plants sometimes used although regarded as not officinal. It is possible that one or two of these seven plants have medical properties, but this can hardly be true of a larger number unless we are disposed to believe that the Indians [pg 328]are better informed in this regard than the best educated white physicians in the country. Two of these seven plants, however (Nos. 2 and 4), belong to genera which seem to have some of the properties ascribed by the Indians to the species. Five others of the list (Nos. 8, 9, 11, 14, and 16) are used for entirely wrong purposes, taking the Dispensatory as authority, and three of these are evidently used on account of some fancied connection between the plant and the disease, according to the doctrine of signatures. Three of the remainder (Nos. 1, 3, and 6) may be classed as uncertain in their properties, that is, while the plants themselves seem to possess some medical value, the Indian mode of application is so far at variance with recognized methods, or their own statements are so vague and conflicting, that it is doubtful whether any good can result from the use of the herbs. Thus the Unaste´tstiyû, or Virginia Snakeroot, is stated by the Dispensatory to have several uses, and among other things is said to have been highly recommended in intermittent fevers, although alone it is “generally inadequate to the cure.” Though not expressly stated, the natural inference is that it must be applied internally, but the Cherokee doctor, while he also uses it for fever, takes the decoction in his mouth and blows it over the head and shoulders of the patient. Another of these, the Distai´yĭ, or Turkey Pea, is described in the Dispensatory as having roots tonic and aperient. The Cherokees drink a decoction of the roots for a feeling of weakness and languor, from which it might be supposed that they understood the tonic properties of the plant had not the same decoction been used by the women as a hair wash, and by the ball players to bathe their limbs, under the impression that the toughness of the roots would thus be communicated to the hair or muscles. From this fact and from the name of the plant, which means at once hard, tough, or strong, it is quite probable that its roots are believed to give strength to the patient solely because they themselves are so strong and not because they have been proved to be really efficacious. The remaining five plants have generally pronounced medicinal qualities, and are used by the Cherokees for the very purposes for which, according to the Dispensatory, they are best adapted; so that we must admit that so much of their practice is correct, however false the reasoning by which they have arrived at this result.

Cherokee Theory of Disease, Animals, Ghosts and Witches

CHEROKEE THEORY OF DISEASE—ANIMALS, GHOSTS, WITCHES.

Such is the belief upon which their medical practice is based, and whatever we may think of the theory it must be admitted that the practice is consistent in all its details with the views set forth in the myth. Like most primitive people the Cherokees believe that disease and death are not natural, but are due to the evil influence of animal spirits, ghosts, or witches. Haywood, writing in 1823, states on the authority of two intelligent residents of the Cherokee nation:

In ancient times the Cherokees had no conception of anyone dying a natural death. They universally ascribed the death of those who perished by disease to the intervention or agency of evil spirits and witches and conjurers who had connection with the Shina (Anisgi´na) or evil spirits.... A person dying by disease and charging his death to have been procured by means of witchcraft or spirits, by any other person, consigns that person to inevitable death. They profess to believe that their conjurations have no effect upon white men.

On the authority of one of the same informants, he also mentions the veneration which “their physicians have for the numbers four and seven, who say that after man was placed upon the earth four and seven nights were instituted for the cure of diseases in the human body and the seventh night as the limit for female impurity.”

Viewed from a scientific standpoint, their theory and diagnosis are entirely wrong, and consequently we can hardly expect their therapeutic system to be correct. As the learned Doctor Berendt states, after an exhaustive study of the medical books of the Mayas, the scientific value of their remedies is “next to nothing.” It must be admitted that many of the plants used in their medical practice possess real curative properties, but it is equally true that many others held in as high estimation are inert. It seems probable that in the beginning the various herbs and other plants were regarded as so many fetiches and were selected from some fancied connection with the disease animal, according to the idea known to modern folklorists as the doctrine of signatures. Thus at the present day the doctor puts into the decoction intended as a vermifuge some of the [red fleshy stalks of the common purslane or chickweed (Portulaca oleracea), because these stalks somewhat resemble worms and consequently must have some occult influence over worms. Here the chickweed is a fetich precisely as is the flint arrow head which is put into the same decoction, in order that in the same mysterious manner its sharp cutting qualities may be communicated to the liquid and enable it to cut the worms into pieces. In like manner, biliousness is called by the Cherokees dalâ´nĭ or “yellow,” because the most apparent symptom of the disease is the vomiting by the patient of the yellow bile, and hence the doctor selects for the decoction four different herbs, each of which is also called dalânĭ, because of the color of the root, stalk, or flower. The same idea is carried out in the tabu which generally accompanies the treatment. Thus a scrofulous patient must abstain from eating the meat of a turkey, because the fleshy dewlap which depends from its throat somewhat resembles an inflamed scrofulous eruption. On killing a deer the hunter always makes an incision in the hind quarter and removes the hamstring, because this tendon, when severed, draws up into the flesh; ergo, any one who should unfortunately partake of the hamstring would find his limbs draw up in the same manner.

There can be no doubt that in course of time a haphazard use of plants would naturally lead to the discovery that certain herbs are efficacious in certain combinations of symptoms. These plants would thus come into more frequent use and finally would obtain general recognition in the Indian materia medica. By such a process of evolution an empiric system of medicine has grown up among the Cherokees, by which they are able to treat some classes of ailments with some degree of success, although without any intelligent idea of the process involved. It must be remembered that our own medical system has its remote origin in the same mythic conception of disease, and that within two hundred years judicial courts have condemned women to be burned to death for producing sickness by spells and incantations, while even at the present day our faith-cure professors reap their richest harvest among people commonly supposed to belong to the intelligent classes. In the treatment of wounds the Cherokee doctors exhibit a considerable degree of skill, but as far as any internal ailment is concerned the average farmer’s wife is worth all the doctors in the whole tribe.

The faith of the patient has much to do with his recovery, for the Indian has the same implicit confidence in the shaman that a child has in a more intelligent physician. The ceremonies and prayers are well calculated to inspire this feeling, and the effect thus produced upon the mind of the sick man undoubtedly reacts favorably upon his physical organization.

The following list of twenty plants used in Cherokee practice will give a better idea of the extent of their medical knowledge than could be conveyed by a lengthy dissertation. The names are given in the order in which they occur in the botanic notebook filled on the reservation, excluding names of food plants and species not identified, so that no attempt has been made to select in accordance with a preconceived theory. Following the name of each plant are given its uses as described by the Indian doctors, together with its properties as set forth in the United States Dispensatory, one of the leading pharmacopœias in use in this country. For the benefit of those not versed in medical phraseology it may be stated that aperient, cathartic, and deobstruent are terms applied to medicines intended to open or purge the bowels, a diuretic has the property of exciting the flow of urine, a diaphoretic excites perspiration, and a demulcent protects or soothes irritated tissues, while hæmoptysis denotes a peculiar variety of blood-spitting and aphthous is an adjective applied to ulcerations in the mouth.

About Cherokee Indians and Their Medical Practice

ABOUT CHEROKEE INDIAN MEDICAL PRACTICE.

Taking the Dispensatory as the standard, and assuming that this list is a fair epitome of what the Cherokees know concerning the medical properties of plants, we find that five plants, or 25 per cent of the whole number, are correctly used; twelve, or 60 per cent, are presumably either worthless or incorrectly used, and three plants, or 15 per cent, are so used that it is difficult to say whether they are ]of any benefit or not. Granting that two of these three produce good results as used by the Indians, we should have 35 per cent, or about one-third of the whole, as the proportion actually possessing medical virtues, while the remaining two-thirds are inert, if not positively injurious. It is not probable that a larger number of examples would change the proportion to any appreciable extent. A number of herbs used in connection with these principal plants may probably be set down as worthless, inasmuch as they are not named in the Dispensatory.

The results here arrived at will doubtless be a surprise to those persons who hold that an Indian must necessarily be a good doctor, and that the medicine man or conjurer, with his theories of ghosts, witches, and revengeful animals, knows more about the properties of plants and the cure of disease than does the trained botanist or physician who has devoted a lifetime of study to the patient investigation of his specialty, with all the accumulated information contained in the works of his predecessors to build upon, and with all the light thrown upon his pathway by the discoveries of modern science. It is absurd to suppose that the savage, a child in intellect, has reached a higher development in any branch of science than has been attained by the civilized man, the product of long ages of intellectual growth. It would be as unreasonable to suppose that the Indian could be entirely ignorant of the medicinal properties of plants, living as he did in the open air in close communion with nature; but neither in accuracy nor extent can his knowledge be compared for a moment with that of the trained student working upon scientific principles.

Cherokee medicine is an empiric development of the fetich idea. For a disease caused by the rabbit the antidote must be a plant called “rabbit’s food,” “rabbit’s ear,” or “rabbit’s tail;” for snake dreams the plant used is “snake’s tooth;” for worms a plant resembling a worm in appearance, and for inflamed eyes a flower having the appearance and name of “deer’s eye.” A yellow root must be good when the patient vomits yellow bile, and a black one when dark circles come about his eyes, and in each case the disease and the plant alike are named from the color. A decoction of burs must be a cure for forgetfulness, for there is nothing else that will stick like a bur; and a decoction of the wiry roots of the “devil’s shoestrings” must be an efficacious wash to toughen the ballplayer’s muscles, for they are almost strong enough to stop the plowshare in the furrow. It must be evident that under such a system the failures must far outnumber the cures, yet it is not so long since half our own medical practice was based upon the same idea of correspondences, for the mediæval physicians taught that similia similibus curantur, and have we not all heard that “the hair of the dog will cure the bite?”

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Their ignorance of the true medical principles involved is shown by the regulations prescribed for the patient. With the exception of the fasting, no sanitary precautions are taken to aid in the recovery of the sick man or to contribute to his comfort. Even the fasting is as much religious as sanative, for in most cases where it is prescribed the doctor also must abstain from food until sunset, just as in the Catholic church both priest and communicants remain fasting from midnight until after the celebration of the divine mysteries. As the Indian cuisine is extremely limited, no delicate or appetizing dishes are prepared for the patient, who partakes of the same heavy, sodden cornmeal dumplings and bean bread which form his principal food in health. In most cases certain kinds of food are prohibited, such as squirrel meat, fish, turkey, etc.; but the reason is not that such food is considered deleterious to health, as we understand it, but because of some fanciful connection with the disease spirit. Thus if squirrels have caused the illness the patient must not eat squirrel meat. If the disease be rheumatism, he must not eat the leg of any animal, because the limbs are generally the seat of this malady. Lye, salt, and hot food are always forbidden when there is any prohibition at all; but here again, in nine cases out of ten, the regulation, instead of being beneficial, serves only to add to his discomfort. Lye enters into almost all the food preparations of the Cherokees, the alkaline potash taking the place of salt, which is seldom used among them, having been introduced by the whites. Their bean and chestnut bread, cornmeal dumplings, hominy, and gruel are all boiled in a pot, all contain lye, and are all, excepting the last, served up hot from the fire. When cold their bread is about as hard and tasteless as a lump of yesterday’s dough, and to condemn a sick man to a diet of such dyspeptic food, eaten cold without even a pinch of salt to give it a relish, would seem to be sufficient to kill him without any further aid from the doctor. The salt or lye so strictly prohibited is really a tonic and appetizer, and in many diseases acts with curative effect. So much for the health regimen.

In serious cases the patient is secluded and no strangers are allowed to enter the house. On first thought this would appear to be a genuine sanitary precaution for the purpose of securing rest and quiet to the sick man. Such, however, is not the case. The necessity for quiet has probably never occurred to the Cherokee doctor, and this regulation is intended simply to prevent any direct or indirect contact with a woman in a pregnant or menstrual condition. Among all primitive nations, including the ancient Hebrews, we find an elaborate code of rules in regard to the conduct and treatment of women on arriving at the age of puberty, during pregnancy and the menstrual periods, and at childbirth. Among the Cherokees the presence of a woman under any of these conditions, or even the presence of any one who has come from a house where such a woman resides, is considered to neutralize all the effects of the doctor’s treatment. For this reason all women, excepting those of the household, are excluded. A man is forbidden to enter, because he may have had intercourse with a tabued woman, or may have come in contact with her in some other way; and children also are shut out, because they may have come from a cabin where dwells a woman subject to exclusion. What is supposed to be the effect of the presence of a menstrual woman in the family of the patient is not clear; but judging from analogous customs in other tribes and from rules still enforced among the Cherokees, notwithstanding their long contact with the whites, it seems probable that in former times the patient was removed to a smaller house or temporary bark lodge built for his accommodation whenever the tabu as to women was prescribed by the doctor. Some of the old men assert that in former times sick persons were removed to the public townhouse, where they remained under the care of the doctors until they either recovered or died. A curious instance of this prohibition is given in the second Didûⁿlĕ´skĭ (rheumatism) formula from the Gahuni manuscript  where the patient is required to abstain from touching a squirrel, a dog, a cat, a mountain trout, or a woman, and must also have a chair appropriated to his use alone during the four days that he is under treatment.

In cases of the children’s disease known as Gûⁿwani´gista´ĭ (see formulas) it is forbidden to carry the child outdoors, but this is not to procure rest for the little one, or to guard against exposure to cold air, but because the birds send this disease, and should a bird chance to be flying by overhead at the moment the napping of its wings would fan the disease back into the body of the patient.