BLACKS

MEDICAL
DICTIONARY
 BLACKS
MEDICAL
DICTIONARY
41 S T EDITION

Edited by
Dr Har vey Marcovitch

A & C Bl ac k Lo n d o n
 41st edition published 2005
A & C Black Publishers Limited
37 Soho Square, London W1D 3QZ
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ISBN 0713661461
eISBN-13: 978-1-4081-0419-4
2005 A & C Black Publishers Limited

A CIP catalogue record for this book is available from the British Library

All rights reserved. No part of this publication may be reproduced in any

form or by any means graphic, electronic or mechanical, including
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systems without the prior permission in writing of the publishers.

In its earlier editions Blacks Medical Dictionary was edited by:

J. D. Comrie, MDfirst to seventeenth editions, 19061942
H. A. Clegg, FRCPeighteenth edition, 1944
W. A. R. Thomson, MDnineteenth to thirty-fourth editions,
19481984
C. W. H. Havard, FRCPthirty-fifth and thirty-sixth editions, 1987
and 1990
G. Macpherson, MB, BSthirty-seventh to fortieth editions, 19922002

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harvested from managed sustainable forests.

Typeset in Adobe Garamond by RefineCatch Limited, Bungay, Suffolk

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 C O N T E N TS

Preface vii

Dictionary 1782

Appendices
1 Basic first aid 783

2 Addresses: sources of information, advice, support

and self-help 787

3 Travel and health 795

4 Common medical tests and procedures 797

5 Vitamins 801

6 Measurements in medicine 804

7 Statutory organisations 807

8 Professional organisations 810

9 Health-policy research organisations 813

Colour section between 416 & 417

 P R E FAC E

Blacks Medical Dictionary first appeared in 1906. That new century

was to see health care in the United Kingdom evolve from a largely
personal, paternalistic consultation between doctor and patient,
based more on medical tradition than medical science, to a complex,
science-based, team-oriented and managed service. Even so, the core
of medical practice has survived: the face-to-face consultation
between doctor and patient. But the nature of this core activity has
been irreversibly altered by a shift in the balance of power between
the participants as patients became better informed about their
health, illnesses and possible treatments. A significant catalyst in the
emergence of the informed patient has been the media, including
publications like this dictionary, the contents of which have during
its 41 editions reflected these changes in medicine.
One modest constant in this sea of change, however, has been the
objective of Blacks Medical Dictionary. When launching the first
edition, the editor, Edinburgh physician John D. Comrie, declared
his aim as being to produce a work which would occupy a position
somewhere between that of a Technical Dictionary of Medicine and
one intended merely for the domestic treatment of common ailments
. . . [giving] information in simple language upon medical subjects of
importance and general interest. That initial mission-statement
underpins this first edition of the 21st century.
Entries in the 41st edition have undergone major revision where
medical knowledge or research has resulted in greater understanding
or changed practice. These include anaesthesia, breast screening and
mammography, chronic fatigue syndrome, clinical guidelines, clin-
ical trials, evidence-based medicine, Gulf War syndrome, hormone
replacement therapy and post-traumatic stress disorder. Ironically the
greatest changes in British medicine seem to be taking place in how
doctors are required to work, rather than what they actually do.
Many of the bodies which constitute the National Health Service
have been replaced or merged, new ones have come into existence
viii Preface

and functions changed. I predict that such reorganisation will con-

tinue throughout the life of this edition, so readers wishing to check
on how the NHS works may need to refer to other sources to be
absolutely sure of remaining up-to-date.

Blacks Medical Dictionary is neither a textbook of medicine nor

a formulary of therapeutic drugs. The many drugs that are
included are given their generic title as used in the British
Pharmacopoeia. Patients are individuals who react in varying
ways to injuries, diseases and their treatments. Appendix 1
explains some basic first-aid procedures, but patients own doc-
tors are normally the appropriate source for personal medical
advice. The dictionary should, however, help readers to decide
when it would be wise to seek medical advice and subsequently
help them to set such advice in context.

Although every effort has been made to ensure accuracy, neither

the publishers nor the author can be held responsible for any
consequences if readers use the book for the treatment of them-
selves or others.

Acknowledgements
I am grateful to colleagues who have updated or rewritten entries.
They include: Dr Phil Alderson, Professor Michael Baum, Dr Karin
Fuchs, Dr Pamela Laurie, Dr Richard Lehman, Mr John McGarry,
Dr Klim McPherson, Mr Michael Paynton, Dr Rob Miller and
Professor Simon Wessely.
Harvey Marcovitch

Note: The use of small capitals for instance stomach, refers the reader to the
entry of that name for additional information.
 when food is taken into the STOMACH, and the

A various important movements of the organs

associated with digestion. The shape of the
abdomen varies; in children it may protrude
considerably, though if this is too marked it
may indicate disease. In healthy young adults it
should be either slightly prominent or slightly
A & E Medicine indrawn, and should show the outline of the
See ACCIDENT AND EMERGENCY MEDICINE. muscular layer, especially of the pair of muscles
running vertically (recti), which are divided
Abdomen into four or five sections by transverse lines. In
The lower part of the trunk. Above, and separ- older people fat is usually deposited on and
ated from it by the diaphragm, lies the thorax or inside the abdomen. In pregnancy the abdomen
chest, and below lies the PELVIS, generally enlarges from the 12th week after conception as
described as a separate cavity though continu- the FETUS in the UTERUS grows (see PREGNANCY
ous with that of the abdomen. Behind are the AND LABOUR; ANTENATAL CARE).
SPINAL COLUMN and lower ribs, which come
within a few inches of the iliac bones. At the Contents The principal contents of the
sides the contained organs are protected by the abdominal cavity are the digestive organs, i.e.
iliac bones and down-sloping ribs, but in front the stomach and INTESTINE, and the associated
the whole extent is protected only by soft tis- glands, the LIVER and PANCREAS. The position
sues. The latter consist of the skin, a varying
amount of fat, three layers of broad, flat muscle,
another layer of fat, and finally the smooth, thin
PERITONEUM which lines the whole cavity.
These soft tissues allow the necessary distension

Contents of the abdomen in position.

of the stomach is above and to the left when the

individual is lying down, but may be much
lower when standing. The liver lies above and
to the right, largely under cover of the ribs, and
occupying the hollow of the diaphragm. The
two KIDNEYS lie against the back wall on either
side, protected by the last two ribs. From the
kidneys run the URETERS, or urinary ducts,
down along the back wall to the URINARY
BLADDER in the pelvis. The pancreas lies across
the spine between the kidneys, and on the
Regions of the abdomen. upper end of each kidney is a suprarenal gland
 2 Abdomen, Diseases of

PANCREAS, DISEASES OF; GALL-BLADDER, DIS-

A EASES OF; KIDNEYS, DISEASES OF; URINARY
BLADDER, DISEASES OF; HERNIA; PERITONITIS;
APPENDICITIS; TUMOUR.
Various processes that can occur include
inflammation, ulceration, infection or tumour.
Abdominal disease may be of rapid onset,
described as acute, or more long-term when it is
termed chronic.
An acute abdomen is most commonly
caused by peritonitis inflammation of the
membrane that lines the abdomen. If any struc-
ture in the abdomen gets inflamed, peritonitis
may result. Causes include injury, inflamma-
tion of the Fallopian tubes (SALPINGITIS), and
intestinal disorders such as APPENDICITIS,
CROHNS DISEASE, DIVERTICULITIS or a perfor-
ated PEPTIC ULCER. Disorders of the GALL-
BLADDER or URINARY TRACT may also result in
acute abdominal pain.
General symptoms of abdominal disease
include:

Pain This is usually ill-defined but can be very

unpleasant, and is termed visceral pain. Pain is
initially felt near the mid line of the abdomen.
Position of renal system on rear wall of abdomen. Generally, abdominal pain felt high up in the
mid line originates from the stomach and duo-
(see ADRENAL GLANDS). The SPLEEN is posi- denum. Pain that is felt around the umbilicus
tioned high up on the left and partly behind the arises from the small intestine, appendix and
stomach. The great blood vessels and nerves lie first part of the large bowel, and low mid-line
on the back wall, and the remainder of the pain comes from the rest of the large bowel. If
space is taken up by the intestines or bowels (see the diseased organ secondarily inflames or
INTESTINE). The large intestine lies in the flanks infects the lining of the abdominal wall the
on either side in front of the kidneys, crossing PERITONEUM peritonitis occurs and the pain
below the stomach from right to left, while the becomes more defined and quite severe, with
small intestine hangs from the back wall in coils local tenderness over the site of the diseased
which fill up the spaces between the other organ itself. Hence the pain of appendicitis
organs. Hanging down from the stomach in begins as a vague mid-line pain, and only later
front of the bowels is the OMENTUM, or apron, moves over to the right iliac fossa, when the
containing much fat and helping to protect the inflamed appendix has caused localised periton-
bowels. In pregnancy the UTERUS, or womb, itis. PERFORATION of one of the hollow organs
rises up from the pelvis into the abdomen as it in the abdomen for example, a ruptured
increases in size, lifting the coils of the small appendix or a gastric or duodenal ulcer (see
intestine above it. STOMACH, DISEASES OF) eroding the wall of the
The PELVIS is the part of the abdomen within gut usually causes peritonitis with resulting
the bony pelvis (see BONE), and contains the severe pain.
rectum or end part of the intestine, the bladder, The character of the pain is also important. It
and in the male the PROSTATE GLAND; in the may be constant, as occurs in inflammatory dis-
female the uterus, OVARIES, and FALLOPIAN eases and infections, or colicky (intermittent) as
TUBES. in intestinal obstruction.

Abdomen, Acute Swelling The commonest cause of abdom-

See ABDOMEN, DISEASES OF. inal swelling in women is pregnancy. In disease,
swelling may be due to the accumulation of
Abdomen, Diseases of trapped intestinal contents within the bowel,
See under STOMACH, DISEASES OF; INTESTINE, the presence of free fluid (ascites) within the
DISEASES OF; DIARRHOEA; LIVER, DISEASES OF; abdomen, or enlargement of one or more of the
 Abortion 3

abdominal organs due to benign causes or Abnormal A

tumour. A structure or process that is not normal
(typical, usual or conforming to the standard);
Constipation is the infrequent or differing from the usual condition of the
incomplete passage of FAECES; sometimes only body.
flatus can be passed and, rarely, no bowel
movements occur (see main entry for CONSTIPA- ABO Blood Groups
TION). It is often associated with abdominal See BLOOD GROUPS.
swelling. In intestinal obstruction, the onset of
symptoms is usually rapid with complete con- Abortifacient
stipation and severe, colicky pain. In chronic An abortifacient is a drug which causes artificial
constipation, the symptoms occur more ABORTION.
gradually.
Abortion
Nausea and vomiting may be due to irri- Abortion is defined as the expulsion of a FETUS
tation of the stomach, or to intestinal obstruc- before it is normally viable, usually before 24
tion when it may be particularly foul and per- weeks of pregnancy. (There are exceptional
sistent. There are also important non- cases nowadays in which fetuses as young as 22
abdominal causes, such as in response to severe weeks gestation have survived.) (See also PREG-
pain or motion sickness. NANCY AND LABOUR.)

Diarrhoea is most commonly due to simple Spontaneous abortion Often called mis-
and self-limiting infection, such as food poison- carriage, this may occur at any time before 28
ing, but may also indicate serious disease, espe- weeks; 85 per cent occur in the first 12 weeks of
cially if it is persistent or contains blood (see main pregnancy. Of all diagnosed pregnancies, 25 per
entry for DIARRHOEA). cent end in spontaneous abortion.
Spontaneous abortions occurring in early
Jaundice is a yellow discoloration of the skin pregnancy are almost always associated with
and eyes, and may be due to disease in the liver chromosomal abnormalities of the fetus. Other
or bile ducts (see main entry for JAUNDICE). causes are uterine shape, maternal disorders
such as DIABETES MELLITUS, diseases of the
Diagnosis and treatment Abdominal dis- thyroid gland (see under ENDOCRINE GLANDS),
eases are often difficult to diagnose because of and problems with the immune system (see
the multiplicity of the organs contained within IMMUNITY). Recurrent spontaneous abortion
the abdomen, their inconstant position and the (that is, three or more) seems to be a particular
vagueness of some of the symptoms. Correct problem in women who have an abnormal
diagnosis usually requires experience, often response of their immune system to pregnancy.
supplemented by specialised investigations such Other factors include being older, having had
as ULTRASOUND. For this reason sufferers a lot of babies previously, cigarette smoking
should obtain medical advice at an early stage, and spontaneous (but not therapeutic) abortions
particularly if the symptoms are severe, persist- in the past.
ent, recurrent, or resistant to simple remedies. Early ULTRASOUND scans have altered the
management of spontaneous abortions. These
Abducent Nerve make it possible to distinguish between threat-
This is the sixth nerve rising from the brain and ened abortion, where a woman has had some
controls the external rectus muscle of the EYE, vaginal bleeding but the fetus is alive; inevitable
which turns the eye outwards. It is particularly abortion, where the neck of the uterus has
liable to be paralysed in diseases of the nervous started to open up; incomplete abortion, where
system, thus leading to an inward squint. part of the fetus or placenta is lost but some
remains inside the uterus; and complete abor-
Abduct tion. There is no evidence that bed rest is effect-
To abduct means to move a part of the body ive in stopping a threatened abortion becoming
for example, a limb away from the mid line. inevitable.
(Opposite: ADDUCT.) Inevitable or incomplete abortion will usu-
ally require a gynaecologist to empty (evacuate)
Ablation the uterus. (Complete miscarriage requires no
Ablation means the removal of any part of the treatment.) Evacuation of the uterus is carried
body by a surgical operation. out using local or general anaesthetic, usually
 4 Abortion

gentle dilatation of the neck of the uterus (cer- surgical or medical, with the latter being used
A vix), and curetting-out the remaining products more and the former less as time goes on.
of the pregnancy. Proper consent must be obtained, signed for
A few late abortions are associated with the and witnessed. Women under 16 years of age
cervix opening too early, abnormal structural can consent to termination provided that the
abnormalities of the uterus, and possibly infec- doctors obtaining the consent are sure she
tion in the mother. clearly understands the procedure and its impli-
Drugs are often used to suppress uterine con- cations. Parental consent in the under-16s is
tractions, but evidence-based studies show that not legally required, but counselling doctors
these do not generally improve fetal salvage. In have a duty to record that they have advised
proven cases of cervical incompetence, the cer- young people to inform their parents. However,
vix can be closed with a suture which is many youngsters do not do so. The womans
removed at 37 weeks gestation. The evidence partner has no legal say in the decision to ter-
for the value of this procedure is uncertain. minate her pregnancy.

Therapeutic abortion In the UK, before MEDICAL METHODS A combination of two

an abortion procedure is legally permitted, two drugs, mifepristone and a prostaglandin (or
doctors must agree and sign a form defined a prostaglandin-like drug, misoprostol see
under the 1967 Abortion Act that the continu- PROSTAGLANDINS), may be used to terminate a
ation of the pregnancy would involve risk pregnancy up to 63 days gestation. A similar
greater than if the pregnancy were terminated regime can be used between nine and 12 weeks
of injury to the physical and/or mental health but at this gestation there is a 5 per cent risk of
of the mother or any existing child(ren). post-treatment HAEMORRHAGE.
Legislation in 1990 modified the Act, which An ultrasound scan is first done to confirm
had previously stated that, at the time of the pregnancy and gestation. The sac containing
abortion, the pregnancy should not have the developing placenta and fetus must be in
exceeded the 24th week. Now, an abortion the uterus; the woman must be under 35 years
may legally be performed if continuing the of age if she is a moderate smoker, but can be
pregnancy would risk the womans life, or the over 35 if she is a non-smoker. Reasons for not
mental health of the woman or her existing using this method include women with diseases
child(ren) is at risk, or if there is a substantial of the ADRENAL GLANDS, on long-term CORTI-
risk of serious handicap to the baby. In 95 per COSTEROIDS, and those who have a haemor-
cent of therapeutic terminations in the UK the rhagic disorder or who are on ANTICOAGU-
reason is risk of injury to the physical or mental LANTS. The drugs cannot be used in women
health of the woman. with severe liver or kidney disease, and caution
There is no time limit on therapeutic abor- is required in those with CHRONIC OBSTRUCT-
tion where the termination is done to save the IVE PULMONARY DISEASE (COPD), disease of the
mothers life, there is substantial risk of serious cardiovascular system, or prosthetic heart valves
fetal handicap, or of grave permanent injury to (see PROSTHESIS), as well as with those who have
the health of the mother. had a CAESAREAN SECTION or an ECTOPIC
About 190,000 terminations are carried out PREGNANCY in the past or who are being treated
in the UK each year and only 11.5 per cent are for HYPERTENSION.
over 20 weeks gestation, with the vast majority Some clinics use this drug combination for
of these late abortions being for severe, late- pregnancies older than 12 weeks. In pregnan-
diagnosed, fetal abnormality. cies approaching viability (20 weeks), pre-
The maternal mortality from therapeutic treatment fetocide (killing of the fetus) with
abortion is less than 1 per 100,000 women and, intrauterine drug therapy may be required.
provided that the procedure is performed skil-
fully by experienced doctors before 12 weeks of SURGICAL METHODS Vacuum curettage is a
pregnancy, it is very safe. There is no evidence method used up to 1415 weeks. Some very
that therapeutic abortion is associated with any experienced gynaecologists will perform abor-
reduction in future fertility, increased rates tions surgically by dilating the cervix and
of spontaneous abortion or preterm birth in evacuating the uterine contents up to 22 weeks
subsequent pregnancies. gestation. The greater the size of the pregnancy,
the higher the risk of haemorrhage and perfor-
Methods of abortion All abortions must ation of the uterus. In the UK, illegal abortion
be carried out in premises licensed for doing so is rare but in other countries this is not the case.
or in NHS hospitals. The method used is either Where illegal abortions are done, the risks of
 Absorption 5

infection and perforation are high and death a CUS) though the latter cause more virulent
definite risk. Legal abortions are generally safe. abscesses. Other abscess-forming organisms are A
In the USA, partial-birth abortions are spoken Pseudomonas pyocyanea and Escherichia coli,
of but, in fact, there is no such procedure which live always in the bowels and under cer-
recorded in the UK medical journals. tain conditions wander into the surrounding
tissues, producing abscesses.
Abrasion The presence of micro-organisms is not suf-
Abrasion means the rubbing-off of the surface ficient in itself to produce suppuration (see
of the skin or of a mucous membrane due to IMMUNITY; INFECTION); streptococci can often
some mechanical injury. Such injuries, though be found on the skin and in the skin glands of
slight in themselves, are apt to allow the perfectly healthy individuals. Whether they will
entrance of dirt-containing organisms, and so to produce abscesses or not depends upon the
lead to an ABSCESS or some more severe form of virulence of the organism and the individuals
inflammation. natural resistance.
When bacteria have gained access for
Treatment The most effective form of treat- example, to a wound they rapidly multiply,
ment consists in the thorough and immediate produce toxins, and cause local dilatation of the
cleansing of the wound with soap and water. An blood vessels, slowing of the bloodstream, and
antiseptic such as 1 per cent cetrimide can then exudation of blood corpuscles and fluid. The
be applied, and a sterile dry dressing. LEUCOCYTES, or white corpuscles of the blood,
collect around the invaded area and destroy the
Abreaction bacteria either by consuming them (see PHAGO-
An emotional release caused by the recall of past CYTOSIS) or by forming a toxin that kills them.
unpleasant experiences. This is normally the If the bodys local defence mechanisms fail to
result of psychoanalytical treatment in which do this, the abscess will spread and may in
psychotherapy, certain drugs, or hypnosis (see severe cases cause generalised infection or
HYPNOTISM) are used to effect the abreaction. SEPTICAEMIA.
The technique is used in the treatment of
anxiety, hysteria, or other neurotic states. Symptoms The classic symptoms of inflam-
mation are redness, warmth, swelling, pain and
Abruptio Placenta fever. The neighbouring lymph nodes may be
Placental bleeding after the 24th week of preg- swollen and tender in an attempt to stop the
nancy, which may result in complete or partial bacteria spreading to other parts of the body.
detachment of the placenta from the wall of the Infection also causes an increase in the number
womb. The woman may go into shock. The of leucocytes in the blood (see LEUCOCYTOSIS).
condition is sometimes associated with raised Immediately the abscess is opened, or bursts,
blood pressure and PRE-ECLAMPSIA. (See also the pain disappears, the temperature falls rap-
PREGNANCY AND LABOUR.) idly to normal, and healing proceeds. If, how-
ever, the abscess discharges into an internal cav-
Abscess ity such as the bowel or bladder, it may heal
A localised collection of pus. A minute abscess slowly or become chronic, resulting in the
is known as a PUSTULE; a diffused production of patients ill-health.
pus is known as CELLULITIS or ERYSIPELAS. An
abscess may be acute or chronic. An acute Treatment Most local infections of the skin
abscess is one which develops rapidly within the respond to ANTIBIOTICS. If pus forms, the
course of a few days or hours. It is characterised abscess should be surgically opened and
by a definite set of symptoms. drained.
Abscesses can occur in any tissue in the body,
Causes The direct cause is various BACTERIA. but the principles of treatment are broadly the
Sometimes the presence of foreign bodies, such same: use of an antibiotic and, where appropri-
as bullets or splinters, may produce an abscess, ate, surgery.
but these foreign bodies may remain buried in
the tissues without causing any trouble pro- Absorption
vided that they are not contaminated by Uptake by the body tissues of fluids or other
bacteria or other micro-organisms. substances. For example, food is absorbed from
The micro-organisms most frequently found the digestive tract into the blood and lymph
are staphylococci (see STAPHYLOCOCCUS), and, systems. Food is absorbed mainly in the small
next to these, streptococci (see STREPTOCOC- INTESTINE ( jejunum and ileum), which is lined
 6 Abstract

by multiple villi that increase its surface area.

A (See also DIGESTION; ASSIMILATION.) Accident and Emergency
Medicine
Accident and Emergency Medicine is the spe-
Abstract cialty responsible for assessing the immediate
(1) A dry powder produced by extracting the needs of acutely ill and injured people. Urgent
active principles from a crude drug. Abstracts treatment is provided where necessary; if
are standardised so as to be twice the strength of required, the patients admission to an
the crude drug. appropriate hospital bed is organised. Every
(2) Summary of scientific paper. part of the UK has nominated key hospitals
with the appropriately trained staff and neces-
Acanthosis Nigricans sary facilities to deal with acutely ill or injured
Acanthosis nigricans is a darkly pigmented ver- patients. It is well-recognised that prompt
rucous skin change, usually occurring around treatment in the first hour or so after an acci-
the neck and axilla. It may be inherited but is dent or after the onset of an acute illness the
most commonly acquired, and is associated so-called golden hour can make the differ-
with adenocarcinoma usually of the stomach ence between the patients recovery and serious
(see CANCER) and certain hormonal disorders disability or death.
such as POLYCYSTIC OVARY SYNDROME, A&E Medicine is a relatively new specialty in
ADDISONS DISEASE and CUSHINGS the UK and there are still inadequate numbers
SYNDROME. of consultants and trainees, despite an inexor-
able rise in the number of patients attending
Acarina A&E departments. With a similar rise in hos-
The group of arthropod insects that include the pital admissions there is often no bed available
parasitic MITES and TICKS. immediately for casualties, resulting in backlogs
of patients waiting for treatment. A major
Acarus debate in the specialty is about the likely need
The group of animal parasites which includes to centralise services by downgrading or closing
Sarcoptes scabiei, the cause of the skin disease smaller units, in order to make the most effi-
known as itch, or SCABIES. This parasite used to cient use of staff.
be known as Acarus scabiei. See www.baem.org.uk
Accidental Death Accommodation
In 2000, more than 12,000 people died in or as The process by which the refractive power of
a result of accidents in the UK, nearly half the lens of the EYE is increased by constriction
occurring at home and around a third in motor of the ciliary muscle, producing an increased
vehicle incidents. Many of these deaths would thickness and curvature of the lens. Rays of
have been preventable, had appropriate safety light from an object further than 6 metres away
measures been taken. A high proportion of are parallel on reaching the eye. These rays are
deaths from accidents occur in males between brought to a focus on the retina, mainly by the
five and 34 years of age; alcohol is a significant cornea. If the eye is now directed at an object
factor. Since the introduction of compulsory
use of car seatbelts in the UK in the 1980s, the
incidence of deaths from driving has fallen.
With employers more aware of the risks of
injury and death in the work place with legis-
lation reinforcing education the number of
such incidents has fallen over the past 50 years
or more: this group now accounts for less than
2 per cent of all accidental deaths. Accidental
deaths in the elderly are mainly caused by falls,
mostly at home. In infants, choking is a signifi-
cant cause of accidental death, with food and
small objects presenting the main hazards. Poi-
soning (often from drug overdose) and drown-
ing are notable causes between the mid-20s and Diagram of eye in relaxed state (1), viewing a dis-
mid-40s. tant object; and in an accommodated state (2) with
See www.rospa.com increased convexity of the lens for viewing a near
object.
 Achalasia of the Cardia 7

closer than 6 metres away, the rays of light from Acetoacetic Acid A
this near object will be diverging by the time An organic acid produced by the LIVER when it
they reach the eye. In order to focus these is rapidly oxidising fatty acids a metabolic
diverging beams of light, the refracting power process which occurs, for example, during star-
of the lens must increase. In other words the vation. The acid produced is then converted to
lens must accommodate. ACETONE, which is excreted.
The lens loses its elasticity with age, and thus
becomes less spherical when tension in the Acetone
zonule relaxes. This results in an increased long-
Acetone is a volatile, colourless organic com-
sightedness (presbyopia) requiring reading
pound of the KETONE group produced by the
glasses for correction. (See AGEING.)
partial oxidation of fatty acids. In some
abnormal conditions, such as starvation,
Accouchement uncontrolled diabetes (see DIABETES MELLITUS)
Archaic term for delivery of a baby (see PREG- or prolonged vomiting, acetone and other
NANCY AND LABOUR). ketones can accumulate in the blood. Acetone
may then appear in the urine, along with beta-
Accretion hydroxybutyric and aceotacic acids, presaging
Addition to an object of the substance of which developing COMA.
it is comprised. An example is the growth of
crystals in a fluid, or overgrowth of bone after
injury. The term also describes foreign material
Acetylcholine
An acetic-acid ester of the organic base choline,
collecting on the surface of a body structure: for
acetylcholine is one of the substances which
example, PLAQUE on teeth.
mediates the transmission of nerve impulses
from one nerve to another, or from a nerve to
Acebutolol the organ it acts on, such as muscles. It acts on
One of the BETA-ADRENOCEPTOR-BLOCKING both muscarinic receptors (blocked by ATRO-
DRUGS (beta blockers) used to treat HYPERTEN- PINE and responsible for ganglionic and para-
SION and ANGINA. Like other beta blockers, it sympathetic transmission and also for sympa-
slows the heart rate and may precipitate heart thetic innervation of sweat glands see under
failure, so should not be given to patients with AUTONOMIC NERVOUS SYSTEM) and nicotinic
incipient heart failure. Acebutolol can be used receptors (responsible for the transmission of
with caution in patients whose heart failure is nerve impulses to muscles and blocked by cur-
satisfactorily controlled. are, thus causing paralysis). Acetylcholine is rap-
idly destroyed by cholinesterase, an ENZYME
ACE Inhibitors present in the blood. ANTICHOLINERGIC drugs
See ANGIOTENSIN-CONVERTING ENZYME (ACE) such as PHYSOSTIGMINE prolong the action of
INHIBITORS. acetylcholine.

Acetabulum Acetylcysteine
The cup-shaped socket on the pelvis in which Acetylcysteine is a MUCOLYTIC drug that is used
rests the head of the femur or thigh-bone, the in the treatment of CYSTIC FIBROSIS and PARA-
two forming the HIP-JOINT. CETAMOL POISONING.

Acetazolamide Acetylsalicyclic Acid

Acetazolamide is a sulphonamide drug which See ASPIRIN.
acts by inhibiting the ENZYME, carbonic anhy-
drase. This enzyme is of great importance in
the production of acid and alkaline secretions Achalasia
in the body. Acetazolamide is sometimes used Achalasia is another term for SPASM, but indi-
as a second-line drug for partial seizures in cates not so much an active spasm of muscle as
EPILEPSY. It also has a diuretic action (see a failure to relax.
DIURETICS) and is used to treat GLAUCOMA.
The drug has a range of side-effects. Related Achalasia of the Cardia
agents include dorzolamide and brinzolamide, A condition in which there is a failure to relax
used as eye-drops in patients resistant to beta of the muscle fibres around the opening of the
blockers or who have contraindications to gullet, or oesophagus, into the stomach. (See
them. OESOPHAGUS, DISEASES OF.)
 8 Achilles Tendon

A Achilles Tendon The normal hydrogen ion concentration of the

A thick tendon that joins the calf muscles to the PLASMA is a constant pH 74, and the lungs and
heel bone (calcaneus) and pulls up that bone. kidneys have a crucial function in maintaining
The tendon is prone to rupture in middle-aged this figure. Changes in pH value will cause
people playing vigorous sports such as squash or ACIDOSIS or ALKALOSIS.
tennis. Named after the classical Greek hero
Achilles, who was reputedly vulnerable to his Acidosis
enemies only in his heel. Acidosis is a condition in which there is either a
production in the body of two abnormal acids
Achlorhydria beta-hydroxybutyric and acetoacetic acids; or a
Achlorhydria means an absence of HYDRO- diminution in the alkali reserve of the blood.
CHLORIC ACID from the STOMACHs secretions.
If the condition persists after the administration Causes The condition is usually due to faulty
of HISTAMINE, the person probably has atrophy metabolism of fat, resulting in the production
of the stomach lining. Achlorhydria occurs in of beta-hydroxybutyric and acetoacetic acids. It
about 4 per cent of healthy people and in sev- occurs in DIABETES MELLITUS when this is
eral conditions, including PERNICIOUS either untreated or inadequately treated, as well
ANAEMIA, carcinoma of the stomach and as in starvation, persistent vomiting, and
GASTRITIS. delayed anaesthetic vomiting. It also occurs in
the terminal stages of glomerulonephritis (see
Achondroplasia KIDNEYS, DISEASES OF), when it is due to failure
The commonest form of inherited retarded of the kidneys. A milder form of it may occur in
growth. It is a dominant hereditary disorder of severe fevers, particularly in children. (See also
endochondral ossification, caused by mutations ACETONE.)
of fibroblast growth factor receptor 3 genes.The
long bones of the arms and legs fail to grow Symptoms General lassitude, vomiting,
properly, while the trunk and head develop thirst, restlessness, and the presence of acetone
normally. Achondroplasia affects both sexes in the urine form the earliest manifestations of
and, while many infants are stillborn or die the condition. In diabetes a state of COMA may
soon after birth, those who survive have normal ensue and the disease end fatally.
intelligence, a normal expectation of life and
good health. Treatment The underlying condition must
always be treated: for example, if the acidosis is
Achromia due to diabetes mellitus then insulin must be
Loss of colour for example, DEPIGMENTATION given. Sodium bicarbonate (see SODIUM) is
of the SKIN or of the iris of the EYE. rarely necessary for diabetic ketoacidosis; if it is
used, it is invariably now given intravenously.
Aciclovir Acidosis might be treated with oral sodium
Aciclovir is an antiviral drug that inhibits bicarbonate in cases of chronic renal failure.
DNA synthesis in cells infected by HERPES Anaesthetists dislike the administration of
VIRUSES, although it does not eradicate them. bicarbonate to acidotic patients, since there is
It is only effective if started at the onset of some evidence that it can make intracellular
infection; uses include the systemic treatment acidosis worse. They almost always use HYPER-
of herpes simplex infections of the skin and VENTILATION of the artificially ventilated
mucous membranes (including genital herpes), patient to correct acidosis.
as well as of varicella-zoster (chickenpox)
pneumonia and encephalitis. It is also used Aciduria
topically in the eye. It is especially valuable for Excretion of an acid URINE.
the treatment of herpes infections in those
with IMMUNODEFICIENCY and may be required Acinus
for the prevention of recurrence and for Acinus is the name applied to each of the min-
prophylaxis indeed, it may be life-saving. ute sacs of which secreting glands are com-
Similar medications include famciclovir and posed, and which usually cluster around the
valaciclovir. branches of the gland-duct like grapes on their
stem. (See GLAND.)
Acid Base Balance
The balance between the acid and alkaline Acne
elements present in the blood and body fluids. A common skin condition starting after
 Acromegaly 9

puberty, and which may persist for many years. Acriflavine A

It involves plugged pores (blackheads and An aniline derivative, this is an orange-red crys-
whiteheads), pimples and deeper nodules on talline powder, readily soluble in water, with
the face, neck, trunk and even the upper arms. strong antiseptic powers.
It arises from pilosebaceous glands (relating to
hair follicles and associated SEBACEOUS Acro-
GLANDS). SEBUM production is increased and Prefix meaning extremity or tip.
bacterial proliferation causes inflammation with
PAPULE and PUSTULE formation. Plugs of Acrocyanosis
sebum and epidermal cells form blackheads A condition, occurring especially in young
(comedones); the colour is not due to dirt but women, in which there is persistent blueness of
to dried oil and shed skin cells in the hair- hands, feet, nose and ears as a result of slow
follicle openings. circulation of blood through the small vessels of
the skin.
Treatment Twice-daily washing with a
salicylic-acid cleanser can help remove the pore- Acromegaly
blocking debris, as can daily shampooing. Use A disorder caused by the increased secretion of
only oil-free cosmetics and hide blackheads growth hormone by an ADENOMA of the
with a flesh-tinted acne lotion containing ben- anterior PITUITARY GLAND. It results in exces-
zoyl peroxide, acid or sulphur. Never squeeze sive growth of both the skeletal and the soft
blackheads, however tempting; ask a skin spe- tissues. If it occurs in adolescence before the
cialist how to do this properly. Other treat- bony epiphyses have fused, the result is gigant-
ments include microdermabrasion, and the ism; if it occurs in adult life the skeletal over-
antibiotic lotions erythromycin and clindamy- growth is confined to the hands, feet, cranial
cin may be effective. Tretinoin and adapilene sinuses and jaw. Most of the features are due to
can be used on the skin but are not permitted in overgrowth of the cartilage of the nose and ear
pregnancy and may cause problems such as and of the soft tissues which increase the thick-
hypersensitivity to sunlight, so medical advice is ness of the skin and lips. Viscera such as the
essential. In resistant cases, long-term suppres- thyroid and liver are also affected. The over-
sive oral therapy with one of the TETRA- growth of the soft tissues is gradual.
CYCLINES or with ERYTHROMYCIN may be The local effects of the tumour commonly
necessary. In females a combined oestrogen- cause headache and, less frequently, impairment
antiandrogen pill is an alternative. Severe of vision, particularly of the temporal field of
resistant acne can be cleared by a 16- to 24- vision, as a result of pressure on the nerves to
week course of oral isotretinoin, but this drug is the eye. The tumour may damage the other
teratogenic (see TERATOGENESIS) and can cause pituitary cells giving rise to gonadal, thyroid or
many side-effects including depression, so its adrenocortical insufficiency. The disease often
use requires specialist supervision. becomes obvious in persons over about 45 years
See www.skincarephysicians.com/acnenet/ of age; they may also complain of excessive
sweating, joint pains and lethargy. The diag-
Acne Rosacea nosis is confirmed by measuring the level of
See ROSACEA. growth hormone in the serum and by an X-ray
of the skull which usually shows enlargement of
Acoustic the pituitary fossa.
Relating to hearing and the response to sound.
For acoustic nerve, see VESTIBULOCOCHLEAR Treatment The most effective treatment is
NERVE. surgically to remove the pituitary adenoma.
This can usually be done through the nose and
Acoustic Neuroma the sphenoid sinus, but large adenomas may
A slow-growing, benign tumour in the auditory need a full CRANIOTOMY. Surgery cures about
canal arising from the Schwann cells of the 80 per cent of patients with a microadenoma
acoustic cranial nerve. The neuroma, which and 40 per cent of those with a large lesion; the
accounts for about 7 per cent of all tumours rate of recurrence is 510 per cent. For recur-
inside the CRANIUM, may cause facial numb- rences, or for patients unfit for surgery or who
ness, hearing loss, unsteady balance, headache, refuse it, a combination of irradiation and drugs
and TINNITUS. It can usually be removed surgi- may be helpful. Deep X-ray therapy to the pitu-
cally, sometimes with microsurgical techniques itary fossa is less effective than surgery but may
that preserve the facial nerve. also be helpful, and recently more sophisticated
 10 Acromion

X-ray techniques, such as gamma knife irradi- the skin and rotating them. Its rationale is that
A ation, have shown promise. Drugs such as disease is a manifestation of a disturbance of
BROMOCRIPTINE, capergoline and quiangoline, Yin and Yang energy in the body, and that acu-
which are dopamine agonists lower growth- puncture brings this energy back into balance
hormone levels in acromegaly and are particu- by what is described as the judicious stimula-
larly useful as an adjunct to radiotherapy. Drugs tion or depression of the flow of energy in the
which inhibit growth-hormone release by various meridians. What is still unclear to
competing for its receptors, octeotride and lan- western doctors is why needling, which is the
reotride, also have a place in treatment. essence of acupuncture, should have the effect it
See www.niddk.nih.gov/health/endo/pubs/ is claimed to have. One theory is that the tech-
acro/acro.htm nique stimulates deep sensory nerves, promot-
www.umm.edu/endocrin/acromegaly.htm ing the production of pain-relieving
ENDORPHINS. Of its efficacy in skilled hands,
Acromion however, there can be no question, and in
That part of the scapula, or shoulder blade, China the technique is an alternative to anaes-
forming the tip of the shoulder and giving its thesia for some operations. Acupuncture is
squareness to the latter. It projects forwards increasingly used in the west, by medically
from the scapula, and, with the CLAVICLE or qualified doctors as well as other practitioners
collar-bone in front, forms a protective arch of of complementary medicine. As long as proper
bone over the shoulder-joint. sterilisation procedures are followed, the treat-
ment is safe: two recent and extensive UK
Acroparaesthesia studies detected no serious adverse effects.
A disorder occurring predominantly in middle-
aged women in which there is numbness and Acute
tingling of the fingers. A condition of short duration that starts
quickly and has severe symptoms. It may also
ACTH (Adrenocorticotrophic refer to a symptom, for example, severe pain.
Hormone) An acute abdomen is a serious disorder of the
ACTH is the commonly used abbreviation for abdomen requiring urgent treatment, usually
CORTICOTROPIN. surgery. Acute heart failure is the sudden stop-
ping of or defect in the action of the heart.
Actinomycin D Acute LEUKAEMIA is a rapid growth in the
See DACTINOMYCIN. number of white blood cells, which is fatal if
untreated. (Opposite: chronic see CHRONIC
Actinomycosis DISORDER.)
A chronic infectious condition caused by an
anaerobic micro-organism, Actinomyces israelii, Acute Life-Threatening Event
that often occurs as a COMMENSAL on the gums, (ALTE)
teeth and tonsils. Commonest in adult men, the See ALTE.
sites most affected are the jaw, lungs and intes-
tine, though the disease can occur anywhere. Acute Respiratory Distress
Suppurating granulomatous tumours develop Syndrome (ARDS)
which discharge an oily, thick pus containing Formerly known as adult respiratory distress
yellowish (sulphur) granules. A slowly progres- syndrome. A form of acute respiratory failure in
sive condition, actinomycosis usually responds which a variety of different disorders give rise to
to antibiotic drugs but improvement may be lung injury by what is thought to be a common
slow and surgery is sometimes needed to drain pathway. The condition has a high mortality
infected sites. Early diagnosis is important. rate (about 70 per cent); it is a complex clinical
Treatment is with antibiotics such as penicillin problem in which a disproportionate immuno-
and tetracyclines. The disease occurs in cattle, logical response plays a major role. (See
where it is known as woody tongue. IMMUNITY.)
The exact trigger is unknown, but it is
Action on Smoking and Health thought that, whatever the stimulus, chemical
See ASH. mediators produced by cells of the immune sys-
tem or elsewhere in the body spread and sustain
Acupuncture an inflammatory reaction. Cascade mechanisms
A traditional Chinese method of healing by with multiple interactions are provoked. CYTO-
inserting thin needles into certain areas beneath TOXIC substances (which damage or kill cells)
 Addisons Disease 11

such as oxygen-free radicals and PROTEASE surfactant through a nebuliser or aerosol may
damage the alveolar capillary membranes (see help to improve lung effectiveness and reduce A
ALVEOLUS). Once this happens, protein-rich oedema. Some experimental evidence supports
fluid leaks into the alveoli and interstitial the use of free-radical scavengers and ANTIOXI-
spaces. SURFACTANT is also lost. This impairs DANTS, but these are not commonly used.
the exchange of oxygen and carbon dioxide in Other techniques include the inhalation of
the lungs and gives rise to the clinical and NITRIC OXIDE (NO) to moderate vascular tone,
pathological picture of acute respiratory failure. and prone positioning to improve breathing. In
The typical patient with ARDS has rapidly severe cases, extracorporeal gas exchange has
worsening hypoxaemia (lack of oxygen in the been advocated as a supportive measure until
blood), often requiring mechanical ventilation. the lungs have healed enough for adequate gas
There are all the signs of respiratory failure (see exchange. (See also RESPIRATORY DISTRESS SYN-
TACHYPNOEA; TACHYCARDIA; CYANOSIS), DROME; HYALINE MEMBRANE DISEASE; SARS.)
although the chest may be clear apart from a
few crackles. Radiographs show bilateral, Acyclovir
patchy, peripheral shadowing. Blood gases will See ACICLOVIR.
show a low PaO2 (concentration of oxygen in
arterial blood) and usually a high PaCO2 Adactyly
(concentration of carbon dioxide in arterial Absence of the digits.
blood). The lungs are stiff they are less effect-
ive because of the loss of surfactant and the Adaptation
PULMONARY OEDEMA. A slowly diminishing reaction of a sense organ
to persistent or repetitive stimulation. For
Causes The causes of ARDS may be broadly example, a persistent smell may after a while
divided into the following: result in the nose failing to signal its presence;
the pressure-sensitive nerve endings in the skin
DIRECT INSULT may become accustomed to the presence of
Viral, bacterial and fungal PNEUMONIA clothes on the body; regular background noise
Lung trauma or contusion may be screened out by the cochlear nerve that
Inhalation of toxic gases or smoke links ear and brain.
ASPIRATION of gastric contents
Near-drowning Addiction
See DEPENDENCE.
INDIRECT INSULT
Septic, haemorrhagic and cardiogenic SHOCK Addisons Disease
METABOLIC DISORDERS such as URAEMIA and The cause of Addisons disease (also called
pancreatitis (see PANCREAS, DISORDERS OF) chronic adrenal insufficiency and hypocortiso-
Bowel infarction lism) is a deficiency of the adrenocortical hor-
Drug ingestion mones CORTISOL, ALDOSTERONE and andro-
Massive blood transfusion, transfusion reac- gens (see ANDROGEN) due to destruction of the
tion (see TRANSFUSION OF BLOOD), CARDIO- adrenal cortex (see ADRENAL GLANDS). It occurs
PULMONARY BYPASS, disseminated intravascular in about 1 in 25,000 of the population. In the
coagulation past, destruction of the adrenal cortex was due
to TUBERCULOSIS (TB), but nowadays fewer
Treatment The principles of management than 20 per cent of patients have TB while 70
are supportive, with treatment of the underlying per cent suffer from autoimmune damage. Rare
condition if that is possible. Oxygenation is causes of Addisons disease include metastases
improved by increasing the concentration of (see METASTASIS) from CARCINOMA, usually of
oxygen breathed in by the patient, usually with the bronchus; granulomata (see GRANULOMA);
mechanical ventilation of the lungs, often using and HAEMOCHROMATOSIS. It can also occur as a
continuous positive airways pressure (CPAP). result of surgery for cancer of the PITUITARY
Attempts are made to reduce the formation of GLAND destroying the cells which produce
pulmonary oedema by careful management of ACTH (ADRENOCORTICOTROPHIC HORMONE)
how much fluid is given to the patient (fluid the hormone which provokes the adrenal
balance). Infection is treated if it arises, as are cortex into action.
the possible complications of prolonged ventila-
tion with low lung compliance (e.g. PNEUMO- Symptoms The clinical symptoms appear
THORAX). There is some evidence that giving slowly and depend upon the severity of the
 12 Adduct

underlying disease process. The patient usually

A complains of appetite and weight loss, nausea, Adeno-
A prefix denoting relation to a GLAND or
weakness and fatigue. The skin becomes pig- glands.
mented due to the increased production of
ACTH. Faintness, especially on standing, is Adenocarcinoma
due to postural HYPOTENSION secondary to A malignant growth of glandular tissue. This
aldosterone deficiency. Women lose their axil- tissue is widespread throughout the bodys
lary hair and both sexes are liable to develop organs and the tumours may occur, for
mental symptoms such as DEPRESSION. Acute example, in the STOMACH, OVARIES and
episodes Addisonian crises may occur, UTERUS. Adenocarcinomas may be subdivided
brought on by infection, injury or other stress- into those that arise from mucous or serous
ful events; they are caused by a fall in aldoster- secreting glandular tissue.
one levels, leading to abnormal loss of sodium
and water via the kidneys, dehydration, low Adenoids
blood pressure and confusion. Patients may See NOSE, DISORDERS OF.
develop increased tanning of the skin from
extra pigmentation, with black or blue dis- Adenolipoma
coloration of the skin, lips, mouth, rectum and A non-malignant tumour arising from the EPI-
vagina occurring. ANOREXIA, nausea and THELIUM and made up of ADIPOSE TISSUE and
vomiting are common and the sufferer may glandular tissues (see GLAND).
feel cold.
Adenoma
Diagnosis This depends on demonstrating A growth or cyst arising from the EPITHELIUM,
impaired serum levels of cortisol and inability a lining layer of cells on the inside of organs.
of these levels to rise after an injection of Although usually benign, adenomas can, as
ACTH. they enlarge, press on adjacent tissue such as
nerves or, in the case of an adenoma of the
PITUITARY GLAND, on brain tissue, causing
Treatment consists in replacement of the
deficient hormones. HYDROCORTISONE tablets symptoms. Where adenomas arise in ENDO-
CRINE GLANDS, such as the adrenals, pancreas,
are commonly used; some patients also require
the salt-retaining hormone, fludrocortisone. pituitary and thyroid, they can provoke exces-
Treatment enables them to lead a completely sive production of the hormone normally
normal life and to enjoy a normal life expect- produced by the gland. If an adenoma is caus-
ancy. Before surgery, or if the patient is preg- ing or is likely to cause symptoms it is usually
nant and unable to take tablets, injectable surgically removed (see also TUMOUR).
hydrocortisone may be needed. Rarely, treated
patients may have a crisis, perhaps because they
Adenomatosis
A condition in which multiple glandular over-
have not been taking their medication or have
growths occur.
been vomiting it. Emergency resuscitation is
needed with fluids, salt and sugar. Because of
this, all patients should carry a card detailing
Adenosine Triphosphate (ATP)
A compound comprising the chemical sub-
their condition and necessary management.
stances adenine, ribose and phosphates. The
Treatment of any complicating infections such
chemical bonds of the phosphates contain
as tuberculosis is essential. Sometimes DIABETES
energy needed for cell METABOLISM that occurs
MELLITUS coexists with Addisons disease and
when muscle cells contract. This energy is made
must be treated.
available when ATP breaks up to form other
Secondary adrenal insufficiency may occur in
chemical groupings adenosine diphosphate
panhypopituitarism (see PITUITARY GLAND), in
(ADP) and adenosine monophosphate (AMP).
patients treated with CORTICOSTEROIDS or after
The energy needed for recombining AMP and
such patients have stopped treatment.
ADP to form ATP is produced by the break-
down of carbohydrates or other constituencies
Adduct of food.
To move a limb or any other part towards the
midline of the body. (Opposite: ABDUCT.) Adenoviruses
Viruses (see VIRUS) containing double-stranded
Adenitis DNA; these cause around 5 per cent of clinic-
Adenitis means inflammation of a GLAND. ally recognised respiratory illnesses. Of the 40
 Adrenal Glands 13

or so known types, only a few have been The term is also used to describe an ingredi-
properly studied to establish how they produce ent added to a VACCINE to boost the immune A
disease. Adenoviruses cause fever and inflam- systems production of antibodies, thus
mation of the respiratory tract and mucous enhancing the vaccines effectiveness in pro-
membranes of the eyes symptoms resembling moting immunity.
those of the common cold. They also cause
ENTERITIS, haemorrhagic CYSTITIS and life- Adler
threatening infections in newborn babies. Alfred Adler (18701937) was an Austrian
Infections are generally benign and self- psychiatrist who proposed psychoanalytical
limiting, and treatment is symptomatic and concepts based on individual psychology, his
supportive, although the elderly and people central thesis being that everyone is born with
with chronic chest conditions may develop sec- intrinsic feelings of inferiority. Thus life is a
ondary infections which require antibiotic continuing struggle to overcome these feelings:
treatment. failure results in neuroses.

ADHD Adolescence
See ATTENTION DEFICIT DISORDER (HYPER- See PUBERTY.
ACTIVITY SYNDROME).
Adoption
Adhesion See CHILD ADOPTION.
The abnormal union of two normally separate
tissues. Adhesion may occur after inflammation Adrenal Glands
or surgery; the result is often a fibrous band Also known as suprarenal glands, these are two
between the adjacent tissues. Examples are small triangular ENDOCRINE GLANDS situated
adhesions between joint surfaces which one upon the upper end of each kidney. (See
reduce mobility of a joint or, after operation, diagram of ABDOMEN.)
between loops of intestine, where the fibrous
band may cause obstruction. Movement of the Structure Each suprarenal gland has an
heart may be restricted by adhesions between enveloping layer of fibrous tissue. Within this,
the organ and its membranous cover, the peri- the gland shows two distinct parts: an outer,
cardial sac. firm, deep-yellow cortical (see CORTEX) layer,
and a central, soft, dark-brown medullary (see
Adipose Tissue MEDULLA) portion. The cortical part consists of
Adipose tissue, or fat, is a loose variety of columns of cells running from the surface
fibrous tissue in the meshes of which lie cells, inwards, whilst in the medullary portion the
each of which is distended by several small cells are arranged irregularly and separated from
drops, or one large drop, of fat. This tissue one another by large capillary blood vessels.
replaces fibrous tissue when the amount of food
taken is in excess of the bodily requirements. Functions Removal of the suprarenal glands
Adipose tissue occurs as a layer beneath the skin in animals is speedily followed by great mus-
and also around several internal organs. (See cular prostration and death within a few days.
DIET; FAT; OBESITY.) In human beings, disease of the suprarenal
glands usually causes ADDISONS DISEASE, in
Adiposis Dolorosa which the chief symptoms are increasing
Also known as Dercums disease. A condition weakness and bronzing of the skin. The
in which painful masses of fat develop under medulla of the glands produces a substance
the skin more common in women than in ADRENALINE the effects of which closely
men. resemble those brought about by activity of
the SYMPATHETIC NERVOUS SYSTEM: dilated
Adiposity pupils, hair standing on end, quickening and
See OBESITY. strengthening of the heartbeat, immobilisation
of the gut, increased output of sugar from the
Adjuvant liver into the bloodstream. Several hormones
Any substance given in concert with another to (called CORTICOSTEROIDS) are produced in
boost its activity. For instance, a CYTOTOXIC the cortex of the gland and play a vital role in
drug used to reinforce radiotherapy or surgery the metabolism of the body. Some (such as
in the treatment of cancer is described as adju- aldosterone) control the electrolyte balance of
vant therapy. the body and help to maintain the blood
 14 Adrenaline

pressure and blood volume. Others are con- specialised fat cells that is particularly relevant
A cerned in carbohydrate metabolism, whilst to the human infant.
others again are concerned with sex physiology. For long it had been realised that in certain
HYDROCORTISONE is the most important hor- cases of ASTHMA, adrenaline had not the usual
mone of the adrenal cortex, controlling as it beneficial effect of dilating the bronchi during
does the bodys use of carbohydrates, fats and an attack; rather it made the asthma worse.
proteins. It also helps to suppress inflammatory This was due to its acting on both the alpha
reactions and has an influence on the immune and beta adrenergic receptors. A derivative,
system. isoprenaline, was therefore produced which
acted only on the beta receptors. This had an
Adrenaline excellent effect in dilating the bronchi, but
Adrenaline is the secretion of the adrenal unfortunately also affected the heart, speeding
medulla (see ADRENAL GLANDS). Its effect is it up and increasing its output an undesirable
similar to stimulation of the SYMPATHETIC effect which meant that isoprenaline had to be
NERVOUS SYSTEM as occurs when a person is used with great care. In due course drugs were
excited, shocked or frightened. In the United produced, such as salbutamol, which act pre-
States Pharmacopoeia it is known as epi- dominantly on the beta2 adrenergic receptors in
nephrine. It is also prepared synthetically. the bronchi and have relatively little effect on
Among its important effects are raising of the the heart.
blood pressure, increasing the amount of glu- The converse of this story was the search for
cose in the blood, and constricting the smaller what became known as BETA-ADRENOCEPTOR-
blood vessels. BLOCKING DRUGS, or beta-adrenergic-blocking
Adrenaline has an important use when drugs. The theoretical argument was that if
injected intramuscularly or intravenously in the such drugs could be synthesised, they could be
treatment of ANAPHYLAXIS. Many patients of value in taking the strain off the heart for
prone to this condition are prescribed a pre- example: stress stimulation of the output of
assembled adrenaline-containing syringe and adrenaline stimulation of the heart
needle (Min-i-Jet, Epipen) and are taught how increased work for the heart. A drug that could
to self-administer in an emergency. Adrenaline prevent this train of events would be of value,
may be applied directly to wounds, on gauze or for example in the treatment of ANGINA PEC-
lint, to check haemorrhage; injected along with TORIS. Now there is a series of beta-
some local anaesthetic it permits painless, adrenoceptor-blocking drugs of use not only in
bloodless operations to be performed on the angina pectoris, but also in various other heart
eye, nose, etc. Nowadays it is rarely, if ever, used conditions such as disorders of rhythm, as well
hypodermically and is no longer given to treat as high blood pressure. They are also proving
ASTHMA. In severe cardiac arrest, adrenaline (1 valuable in the treatment of anxiety states by
in 10,000) by central intravenous injection is preventing disturbing features such as palpita-
recommended. It can be given through an tions. Some are useful in the treatment of
endotracheal tube as part of neonatal migraine.
resuscitation.
Adrenocorticotrophic Hormone
Adrenergic Receptors (ACTH)
The sites in the body on which ADRENALINE See also CORTICOTROPIN. A hormone which is
and comparable stimulants of the SYMPATHETIC released into the body during stress. Made and
NERVOUS SYSTEM act. Drugs which have an stored in the anterior PITUITARY GLAND,
adrenaline-like action are described as being ACTH regulates the production of cortico-
adrenergic. There are five different types of steroid hormones from the ADRENAL GLANDS,
adrenergic receptors, known as alpha1, alpha2, and is vital for the growth and maintenance of
beta1, beta2 and beta3 respectively. Stimulation the adrenal cortical cells. Its production is in
of alpha receptors leads to constriction of the part controlled by the amount of HYDRO-
bronchi, constriction of the blood vessels with CORTISONE in the blood and also by the HYPO-
consequent rise in blood pressure, and dilata- THALAMUS. ACTH participates in the FEED-
tion of the pupils of the eyes. Stimulation of BACK MECHANISM of hormone production and
beta1 receptors quickens the rate and output of actions involving particularly the hypo-
the heart, while stimulation of beta2 receptors thalamus and pituitary gland. The hormone is
dilates the bronchi. Beta3 receptors are now used to test adrenal function and treat condi-
known to mediate so-called non-shivering tions such as ASTHMA. (See also CUSHINGS
thermogenesis, a way of producing heat from SYNDROME.)
 Aerotitis 15

Adrenogenital Syndrome centration of the drug and accord with what is

A
An inherited condition, the adrenogenital syn- known of its PHARMACOLOGY. These so-called
drome also known as congenital adrenal type A (augmented pharmacological) effects are
hyperplasia is an uncommon disorder affect- distinguished from type B (bizarre) effects
ing about 1 baby in 7,500. The condition is which are unpredictable, usually rare, and often
present from birth and causes various ENZYME severe. ANAPHYLAXIS is the most obvious of
defects as well as blocking the production of these; other examples include bone-marrow
HYDROCORTISONE and ALDOSTERONE by the suppression with CO-TRIMOXAZOLE; hepatic
ADRENAL GLANDS. In girls the syndrome often failure (see HEPATITIS) with SODIUM VALPROATE;
produces VIRILISATION of the genital tract, and PULMONARY FIBROSIS with AMIODARONE.
often with gross enlargement of the clitoris and A more comprehensive classification includes
fusion of the labia so that the genitalia may be reactions type C (chronic effects), D (delayed
mistaken for a malformed penis. The metabol- effects such as teratogenesis or carcinogenesis)
ism of salt and water may be disturbed, causing and E (end-of-dose effects withdrawal
dehydration, low blood pressure and weight effects). Examples of adverse reactions include
loss; this can produce collapse at a few days or nausea, skin eruptions, jaundice, sleepiness and
weeks of age. Enlargement of the adrenal headaches.
glands occurs and the affected individual may While most reported adverse reactions are
also develop excessive pigmentation in the minor and require no treatment, patients
skin. should remind their doctors of any drug
When virilisation is noted at birth, great care allergy or adverse effect they have suffered in
must be taken to determine genetic sex by karyo- the past. Medical warning bracelets are easily
typing: parents should be reassured as to the obtained. Doctors should report adverse effects
babys sex (never in between). Blood levels of to the authorities in the case of Britain, to
adrenal hormones are measured to obtain a pre- the Committee on Safety of Medicines
cise diagnosis. Traditionally, doctors have (CSM), using the yellow-card reporting
advised parents to choose their childs gender machinery.
on the basis of discussing the likely condition of
the genitalia after puberty. Thus, where the Ades Aegypti
phallus is likely to be inadequate as a male The scientific name for the mosquito which
organ, it may be preferred to rear the child as conveys to humans (by biting) the viruses of
female. Surgery is usually advised in the first YELLOW FEVER and of DENGUE or break-bone
two years to deal with clitoromegaly but parent/ fever.
patient pressure groups, especially in the US,
have declared it wrong to consider surgery until Aegophony
the children are competent to make their own The bleating or punchinello tone given to the
decision. voice as heard by AUSCULTATION with a stetho-
Other treatment requires replacement of the scope, when there is a small amount of fluid in
missing hormones which, if started early, may the pleural cavity in the chest.
lead to normal sexual development. There is
still controversy surrounding the ethics of gen- Aerobic Bacterium
der reassignment. A bacterium (see BACTERIA) that needs the pres-
See www.baps.org.uk ence of free oxygen for its life and
multiplication.
Advance Statements about
Medical Treatment Aerophagy
See LIVING WILL.
Swallowing abnormal quantities of air which
can occur during rapid eating or drinking.
Adverse Reactions to Drugs Indigestion-sufferers sometimes do this to
When a new drug is introduced, it has usually
been studied only in relatively few patients relieve their symptoms, and it is a common sign
typically 1,500. If n patients have been studied, of anxiety.
and no serious effects observed, there is still a
chance of a serious adverse effect occurring in Aerosol
the general population as frequently as 3/n See INHALANTS.
(1:500).
Adverse effects can be divided into types. Aerotitis
First, those which are closely related to the con- See OTIC BARATRAUMA.
 16 Aetiology

A Aetiology
homeostatic mechanisms; environment and
That part of medical science dealing with the lifestyle also affect the ageing process.
causes of disease. The effects of ageing include: cessation of
MENSTRUATION in females; wrinkling of the
Afferent skin due to a loss of elastic tissue; failing mem-
An adjective to describe nerves, blood vessels or ory (especially short term) and a reduced ability
lymphatic vessels that conduct their electrical to learn new skills, along with slowed responses
charge or contents inwards to the brain, spinal changes caused by the loss of or less efficient
cord or relevant organ. (Opposite: EFFERENT.) working of nerve cells; the senses become less
acute; the lungs become less efficient, as does
Afibrinogenaemia heart muscle, both causing a fall in exercise tol-
A condition in which the blood will not clot erance; arteries harden, resulting in a rise in
because FIBRIN is absent. It is characterised by blood pressure and poor blood circulation;
haemorrhage. There are two forms: (a) a con- joints are less mobile, bones beome more brittle
genital form, and (b) an acquired form. The (OSTEOPOROSIS) and muscle bulk and strength
latter may be associated with advanced liver dis- are reduced; the lens of the EYE becomes less
ease, or may occur as a complication of labour. elastic, resulting in poorer sight, and it may also
Treatment consists of the intravenous injection become opaque (CATARACT).
of fibrinogen, and blood transfusion. (See also In developed countries people are living
COAGULATION.)
longer, in part because infant and child mortal-
ity rates have dropped dramatically over the
past 100 years or so. Improved standards of liv-
Afterbirth ing and more effective health care have also
See PLACENTA.
contributed to greater longevity: the proportion
of people over 65 years of age has greatly
Afterpains increased, and that of the over-75s is still rising.
Pains similar to but feebler than those of labour, The 2001 census found 336,000 people in the
occurring in the two or three days following UK aged over 90 and there are 36,000 centenar-
childbirth. (See PREGNANCY AND LABOUR.) ians in the US. This extreme longevity is attrib-
uted to a particular gene (see GENES) slowing the
Causes are generally the presence of a blood ageing process. Interestingly, those living to 100
clot or retained piece of PLACENTA which the often retain the mental faculties of people in
womb (see UTERUS) is attempting to expel. their 60s, and examination of centenarians
brains show that these are similar to those of
Agammaglobulinaemia 60-year-olds. (See MEDICINE OF AGEING;
An inherited condition found in male infants, CLIMACTERIC.)
in which there is no GAMMA-GLOBULIN in the Help and advice can be obtained from Age
blood. These children are particularly suscep- Concern and Help the Aged.
tible to infections, as they are unable to form See www.helpthaged.org.uk
ANTIBODIES to any infecting micro-organism. www.ageconcern.org.uk
Acquired agammaglobulinaemia is a rare dis-
order occurring in both sexes in their 20s and Agenesis
40s, characterised by recurrent bacterial infec- Agenesis means incomplete development, or
tions. The cause is a disturbance in the working the failure of any part or organ of the body to
of the immune system. (See IMMUNITY.) develop normally.

Agar Agglutination
Also known as agar-agar. A gelatinous substance The adherence together of small bodies in a
made from seaweed, agar is used in preparing fluid. Thus, blood corpuscles agglutinate into
culture-media for use in bacteriological labora- heaps (rouleaux) when added to the serum of a
tories; it is also sometimes used to treat person belonging to an incompatible blood
constipation. group. Bacteria agglutinate into clumps and die
when exposed to the presence of antibodies in
Ageing the blood. This is important in regard to diag-
The result of a combination of natural, largely nosis of certain diseases due to bacteria. In
genetically programmed changes occurring in typhoid fever (see ENTERIC FEVER), for example,
all body systems. Diseases or injuries may influ- the blood of an animal is immunised against
ence these changes, which impair the bodys typhoid bacilli by repeated injections of these.
 AI 17

The blood serum of the animal, known now as Agonist A

anti-typhoid serum, is issued to laboratories for (1) A muscle which contracts and causes a
use when bacilli are found in the excretions of a movement. Contraction of an agonist is com-
patient who is possibly suffering from typhoid plemented by relaxation of its antagonist (see
fever. The bacilli are exposed to the action of a below).
drop of the serum; if the serum shows the (2) A drug that acts through receptors on the
power of agglutinating these bacteria, this surface of the cell or within the cell and pro-
forms evidence that the bacteria in question are vokes a biological response. As the body con-
typhoid bacilli. The reaction may also be car- tains natural agonists that combine with cell
ried out in the contrary manner: that is to say, receptors, any occupation of these cell recep-
the serum from the blood of a patient who may tors by drug molecules will have a pharmaco-
be suffering from typhoid fever, but in whom logical effect on the individual. The intensity of
the diagnosis is still doubtful, is added to a drop that pharmacological effect is believed to be
of fluid containing typhoid bacilli; if these are directly proportional to the number of recep-
agglutinated into clumps by the patients tors on the cell that combine with the drug
serum, the patient is then known to be suffering molecule. For example, the natural agonist nor-
from typhoid fever. If they do not agglutinate, adrenaline contracts the smooth muscle of
the symptoms are due to some other condition. blood vessels; the drug agonist phenylnephrine
This reaction for typhoid fever is known as the has a similar effect.
Widal reaction. Comparable agglutination reac-
tions, using an appropriate serum, are used in Antagonists are drugs which will combine
the diagnosis of a number of diseases, including with the receptor site to prevent another agent
glandular fever (when it is known as the Paul- from producing its greatest effect. If the drug
Bunnell reaction), typhus fever (when it is has no efficacy of its own, but simply prevents
known as the Weil-Felix reaction), undulant the agonist from acting at the receptor site, it is
fever, and Weils disease. (For more information called a full antagonist. A partial antagonist is a
about these diseases, see under separate entries.) drug that provokes some activity at the receptor
site. An example of an antagonist is prazosin,
Agglutinogen which acts against the natural agonist nor-
An ANTIGEN that stimulates production of adrenaline at the receptor site of the cells of
an agglutinin an antibody that causes blood-vessel muscle and prevents the vascular
AGGLUTINATION or clumping of bacteria, blood muscle from contracting.
cells or other antigenic particles. In the case of
blood cells, this should not be confused with Agoraphobia
the clumping that happens in blood COAGULA- A sense of fear experienced in large open spaces
TION, which is a different process. and public places, agoraphobia is a symptom of
psychological disorder (see MENTAL ILLNESS).
Aggression There are said to be 300,000 sufferers in the
A general term that covers a range of hostile United Kingdom. Those who suffer from what
behaviour, some of which may extend beyond can be a most distressing condition can obtain
normal social behaviour. Some physical diseases help and advice from the National Phobics
cause aggressive outbursts: temporal lobe EPI- Society.
LEPSY and hypoglycaemia (see DIABETES MEL-
LITUS) are examples. Certain mental disorders Agranulocytosis
such as antisocial personality disorders, alcohol A condition in which the white cells or LEUCO-
or drug abuse, and SCHIZOPHRENIA may be CYTES in the blood of the polynuclear or granu-
associated with aggression. lar variety become greatly lessened in numbers
Male sex hormones (see under ANDROGEN) or disappear altogether. It is usually caused by
appear to be linked to aggressive behaviour, and taking such drugs as amidopyrine, thiourea,
aggression is more common among adolescents sulphonamides, chloramphenicol and the
and young adults than other sections of the immunosuppressant drugs.
population.
Agraphia
Agnosia Loss of power to express ideas by writing. (See
The condition in which, in certain diseases of APHASIA.)
the brain, the patient loses the ability to recog-
nise the character of objects through the senses AI
touch, taste, sight, hearing. See ARTIFICIAL INTELLIGENCE (AI).
 18 AIDS/HIV

A AIDS/HIV
were newly infected with HIV, and that 3 mil-
Acquired Immune Deficiency Syndrome lion adults and children died. In Africa in 2003,
(AIDS) is the clinical manifestation of infection 3.4 million people were newly infected and 2.3
with Human Immunodeficiency Virus (HIV). million died, with more than 28 million carry-
HIV belongs to the retroviruses, which in turn ing the virus. HIV/AIDS was the leading cause
belong to the lentiviruses (characterised by slow of death in sub-Saharan Africa where over half
onset of disease). There are two main HIV of the infections were in women and 90 per
strains: HIV-1, by far the commonest; and cent of cases resulted from heterosexual sex. In
HIV-2, which is prevalent in Western Africa some southern African countries, one in three
(including Ivory Coast, Gambia, Mali, Nigeria pregnant women had HIV.
and Sierra Leone). HIV attacks the human In Asia and the Pacific there were 1.2 million
immune system (see IMMUNITY) so that the new infections and 435,000 deaths. The area
infected person becomes susceptible to with the fastest-growing epidemic is Eastern
opportunistic infections, such as TUBERCU- Europe, especially the Russian Federation
LOSIS, PNEUMONIA, DIARRHOEA, MENINGITIS where in 2002 around a million people had
and tumours such as KAPOSIS SARCOMA. AIDS HIV and there were an estimated 250,000 new
is thus the disease syndrome associated with infections, with intravenous drug use a key con-
advanced HIV infection. tributor to this figure. Seventy-five per cent of
Both HIV-1 and HIV-2 are predominantly cases occurred in men, with male-to-male sex-
sexually transmitted and both are associated ual transmission an important cause of infec-
with secondary opportunistic infections. How- tion, though heterosexual activity is a rising
ever, HIV-2 seems to result in slower damage cause of infection.
to the immune system. HIV-1 is known to At the end of 2002 the UK had an estimated
mutate rapidly and has given rise to other sub- 55,900 HIV-infected adults aged between 15
types. and 59. More than 3,600 individuals were
HIV is thought to have occurred in humans newly diagnosed with the infection in 2000, the
in the 1950s, but whether or not it infected highest annual figure since the epidemic started
humans from another primate species is in 1998 the figure was 2,817 and in 1999 just
uncertain. It became widespread in the 1970s over 3,000 (Department of Health and Com-
but its latency in causing symptoms meant that municable Disease Surveillance Centre). The
the epidemic was not noticed until the follow- incidence of AIDS in the UK has declined
ing decade. Although it is a sexually transmitted sharply since the introduction of highly active
disease, it can also be transmitted by intraven- antiretroviral therapy (HAART) and HIV-
ous drug use (through sharing an infected related deaths have also fallen: in 2002 there
needle), blood transfusions with infected blood were 777 reported new AIDS cases and 395
(hence the importance of effective national deaths, compared with 1,769 and 1,719
blood-screening programmes), organ donation, respectively in 1995. (Sources: UNAIDS and
and occupationally (see health-care workers, below). WHO, AIDS Epidemic Update, December
Babies born of HIV-positive mothers can be 2001; Public Health Laboratory Services AIDS
infected before or during birth, or through and STD Centre Communicable Disease Sur-
breast feeding. veillance and Scottish Centre for Infection and
Although HIV is most likely to occur in Environmental Health, Quarterly Surveillance
blood, semen or vaginal fluid, it has been found Tables.)
in saliva and tears (but not sweat); however, Poverty is strongly linked to the spread of
there is no evidence that the virus can be trans- AIDS, for various reasons including lack of
mitted from these two body fluids. There is also health education; lack of effective public-health
no evidence that HIV can be transmitted by awareness; women having little control over
biting insects (such as mosquitoes). HIV does sexual behaviour and contraception; and, by
not survive well in the environment and is rap- comparison with the developed world, little or
idly destroyed through drying. no access to antiretroviral drugs.

Prevalence At the end of 2003 an estimated Pathogenesis The cellular target of HIV
42 million people globally were infected with infection is a subset of white blood cells called
HIV up from 40 million two years earlier. T-lymphocytes (see LYMPHOCYTE) which carry
About one-third of those with HIV/AIDS are the CD4 surface receptor. These so-called
aged 1524 and most are unaware that they are helper T-cells are vital to the function of cell-
carrying the virus. During 2003 it is estimated mediated immunity. Infection of these cells
that 5 million adults and children worldwide leads to their destruction (HIV replicates at an
 AIDS/HIV 19

enormous rate 109) and over the course of CENTRAL NERVOUS SYSTEM, the gastrointestinal
several years the body is unable to generate suf- tract or the LUNGS. Patients may present with a A
ficient new cells to keep pace. This leads to pro- sudden onset of a neurological deficit or EPI-
gressive destruction of the bodys immune cap- LEPSY due to a sudden onset of a STROKE-like
abilities, evidenced clinically by the develop- syndrome, or epilepsy due to a space-occupying
ment of opportunistic infection and unusual lesion in the brain most commonly TOXO-
tumours. PLASMOSIS. In late disease, HIV infection of the
central nervous system itself may produce pro-
Monitoring of clinical progression It gressive memory loss, impaired concentration
is possible to measure the number of viral par- and mental slowness called AIDS DEMENTIA. A
ticles present in the plasma. This gives an wide variety of opportunistic PROTOZOA or vir-
accurate guide to the likely progression rate, uses produces DYSPHAGIA, DIARRHOEA and
which will be slow in those individuals with wasting. In the respiratory system the com-
fewer than 10,000 particles per ml of plasma monest opportunistic infection associated with
but progressively more rapid above this figure. AIDS, pneumonia, produces severe shortness of
The main clinical monitoring of the immune breath and sometimes CYANOSIS, usually with a
system is through the numbers of CD4 striking lack of clinical signs in the chest.
lymphocytes in the blood. The normal count is In very late HIV infection, when the CD4
around 850 cells per ml and, without treat- count has fallen below 50 cells per ml, infection
ment, eventual progression to AIDS is likely in with CYTOMEGALOVIRUS may produce progres-
those individuals whose CD4 count falls below sive retinal necrosis (see EYE, DISORDERS OF)
500 per ml. Opportunistic infections occur which will lead to blindness if untreated, as well
most frequently when the count falls below 200 as a variety of gastrointestinal symptoms. At
per ml: most such infections are treatable, and this stage, infection with atypical mycobacteria
death is only likely when the CD4 count falls is also common, producing severe anaemia,
below 50 cells per ml when infection is wasting and fevers. The commonest tumour
developed with organisms that are difficult to associated with HIV is Kaposis sarcoma which
treat because of their low intrinsic virulence. produces purplish skin lesions. This and non-
Simple, cheap and highly accurate tests are Hodgkins lymphoma (see LYMPHOMA), which
available to detect HIV antibodies in the serum. is a hundred times more frequent among HIV-
These normally occur within three months of positive individuals than in the general popula-
infection and remain the cornerstone of the tion, are likely to be associated with or caused
diagnosis. by opportunistic viral infections.

Clinical features Most infected individuals Prevention There is, as yet, no vaccine to
have a viral illness some three weeks after con- prevent HIV infection. Vaccine development
tact with HIV. The clinical features are often has been hampered
non-specific and remain undiagnosed but
include a fine red rash, large lymph nodes, an
by the large number of new HIV strains gen-
erated through frequent mutation and
influenza-like illness, cerebral involvement and recombination.
sometimes the development of opportunistic
infections. The antibody test may be negative at
because HIV can be transmitted as free virus
and in infected cells.
this stage but there are usually high levels of
virus particles in the blood. The antibody test is
because HIV infects helper T-cells the very
cells involved in the immune response.
virtually always positive within three months of There are, however, numerous research pro-
infection. HIV infection is often subsequently grammes underway to develop vaccines that are
asymptomatic for a period of ten years or more, either prophylactic or therapeutic. Vaccine-
although in most patients progressive immune development strategies have included:
destruction is occurring during this time and a recombinant-vector vaccines, in which a live
variety of minor opportunistic infections such bacterium or virus is genetically modified to
as HERPES ZOSTER or oral thrush (see CANDIDA) carry one or more of the HIV genes; subunit
do occur. In addition, generalised LYMPH- vaccines, consisting of small regions of the HIV
ADENOPATHY is present in a third of patients genome designed to induce an immune
and some suffer from severe malaise, weight response without infection; modified live HIV,
loss, night sweats, mild fever, ANAEMIA or easy which has had its disease-promoting genes
bruising due to THROMBOCYTOPENIA. removed; and DNA vaccines small loops of
The presentation of opportunistic infection DNA (plasmids) containing viral genes that
is highly variable but usually involves either the make the host cells produce non-infectious viral
 20 AIDS/HIV

proteins which, in turn, trigger an immune and replication. HAART is also the most effect-
A response and prime the immune system against ive way of preventing opportunistic infections,
future infection with real virus. and has had a significant impact in delaying the
In the absence of an effective vaccine, pre- onset of AIDS in HIV-positive individuals in
venting exposure remains the chief strategy in developed countries.
reducing the spread of HIV. Used properly, Four classes of drugs are currently in use.
condoms are an extremely effective method of Nucleoside analogues, including ZIDOVUDINE
preventing exposure to HIV during sexual and DIDANOSINE, interfere with the activity of
intercourse and remain the most important the unique enzyme of the retrovirus reverse
public-health approach to countering the fur- transcriptase which is essential for replication.
ther acceleration of the AIDS epidemic. The Nucleotide analogues, such as tenofovir, act in
spermicide nonoxynol-9, which is often the same way but require no intracellular acti-
included with condoms, is known to kill HIV vation. Non-nucleoside reverse transcriptase
in vitro; however, its effectiveness in preventing inhibitors, such as nevirapine and EFAVIRENZ,
HIV infection during intercourse is not known. act by a different mechanism on the same
Public-health strategies must be focused on enzyme. The most potent single agents against
avoiding high-risk behaviour and, particularly HIV are the protease inhibitors, such as lopina-
in developing countries, empowering women to vir, which render a unique viral enzyme inef-
have more control over their lives, both eco- fective. These drugs are used in a variety of
nomically and socially. In many of the poorer combinations in an attempt to reduce the
regions of the world, women are economically plasma HIV viral load to below detectable
dependent on men and refusing sex, or insisting limits, which is achieved in approximately 90
on condom use, even when they know their per cent of patients who have not previously
partners are HIV positive, is not a straight- received therapy. This usually also produces a
forward option. Poverty also forces many profound rise in CD4 count. It is likely, how-
women into the sex industry where they are at ever, that such treatments need to be lifelong
greater risk of infection. and since they are associated with toxicities,
Cultural problems in gaining acceptance for long-term adherence is difficult. Thus the
universal condom-use by men in some develop- optimum time for treatment intervention
ing countries suggests that other preventive remains controversial, with some clinicians
strategies should also be considered. Microbi- believing that this should be governed by the
cides used as vaginal sprays or chemical con- viral load rising above 10,000 copies, and
doms have the potential to give women more others that it should primarily be designed to
direct control over their exposure risk, and prevent the development of opportunistic
research is underway to develop suitable infections thus, that initiation of therapy
products. should be guided more by the CD4 count.
Epidemiological studies suggest that male It should be noted that the drug regimens
circumcision may offer some protection against have been devised for infection with HIV-1; it
HIV infection, although more research is is not known how effective they are at treating
needed before this can be an established public- infection with HIV-2.
health strategy. Globally, about 70 per cent of
infected men have acquired the virus through HIV and pregnancy An HIV-positive
unprotected vaginal sex; in these men, infection woman can transmit the virus to her fetus, with
is likely to have occurred through the penis the risk of infection being particularly high
with the mucosal epithelia of the inner surface during parturition; however, the risk of peri-
of the foreskin and the frenulum considered the natal HIV transmission can be reduced by
most likely sites for infection. It is suggested antiviral drug therapy. In the UK, HIV testing
that in circumcised men, the glans may become is available to all women as part of antenatal
keratinised and thus less likely to facilitate care. The benefits of antenatal HIV testing in
infection. Circumcision may also reduce the countries where antiviral drugs are not avail-
risk of lesions caused by other sexually transmit- able are questionable. An HIV-positive
ted disease. woman might be advised not to breast feed
because of the risks of transmitting HIV via
Treatment AIDS/HIV treatment can be cat- breastmilk, but there may be a greater risk
egorised as specific therapies for the individual associated with not breast feeding at all.
opportunistic infections which ultimately Babies in many poor communities are thought
cause death and highly active antiretroviral to be at high risk of infectious diseases and
therapy (HAART) designed to reduce viral load malnutrition if they are not breast fed and
 Air Passages 21

may thus be at greater overall risk of death the number of blood samples taken from a
during infancy. patient, safer-needle devices (such as needles A
that self-blunt after use) and needleless drug
Counselling Confidential counselling is an administration are all thought to reduce the risk
essential part of AIDS management, both in of exposure to HIV and other blood-borne vir-
terms of supporting the psychological well- uses. Although there have been numerous cases
being of the individual and in dealing with of health-care workers developing HIV through
issues such as family relations, sexual partners occupational exposure, there is little evidence of
and implications for employment (e.g. for health-care workers passing HIV to their
health-care workers). Counsellors must be par- patients through normal medical procedures.
ticularly sensitive to culture and lifestyle issues.
Counselling is essential both before an HIV test Air
is taken and when the results are revealed. The general constituents of air are:

Health-care workers Health-care workers per cent

may be at risk of occupational exposure to HIV, Oxygen 2094
either through undertaking invasive procedures Nitrogen 7809
or through accidental exposure to infected Argon 094
blood from a contaminated needle (needlestick Carbon dioxide 003
injury). Needlestick injuries are frequent in
health care as many as 600,000 to 800,000 Besides these, there are always ozone, minerals
are thought to occur annually in the United and organic matter present in small and variable
States. Transmission is much more likely where amounts, and more or less water vapour accord-
the worker has been exposed to HIV through a ing to the weather. In the air of towns, sulphur-
needlestick injury or deep cut with a contamin- ous acid and sulphuretted hydrogen are
ated instrument than through exposure of important impurities derived from combustion.
mucous membranes to contaminated blood or After air has been respired once, the oxygen falls
body fluids. However, even where exposure by about 4 per cent and the carbonic acid rises
occurs through a needlestick injury, the risk of to about 4 per cent, while organic matter and
seroconversion is much lower than with a simi- water vapour are greatly increased and the air
lar exposure to hepatitis C or hepatitis B. A rises in temperature. The cause of the dis-
percutaneous exposure to HIV-infected blood comfort felt in badly ventilated rooms and
in a health-care setting is thought to carry a risk crowded halls is associated with the increase in
of about one infection per 300 injuries (one in the temperature and moisture of the air, but a
1,000 for mucous-membrane exposure), com- high percentage of carbon dioxide may be pres-
pared with one in 30 for hepatitis C, and one in ent without causing any noticeable discomfort
three for hepatitis B (when the source patient is or appreciable quickening of the respiration. A
e-antigen positive). combination of hot weather and emissions
In the event of an injury, health-care workers from vehicles and fossil-fuel combustion pro-
are advised to report the incident immediately duces pollutants linked to a rise in the incidence
where, depending on a risk assessment, they of ASTHMA and other cardiorespiratory condi-
may be offered post-exposure prophylaxis tions. Falling levels of ozone in the upper
(PEP). They should also wash the contamin- atmosphere are also believed to contribute to
ated area with soap and water (but without global warming because ozone screens the earth
scrubbing) and, if appropriate, encourage from most of the suns harmful ultraviolet
bleeding at the site of injury. PEP, using a com- radiation.
bination of antiretroviral drugs (in a similar
regimen to HAART see above), is thought to Air Embolism
greatly reduce the chances of seroconversion; it A bubble of air in a blood vessel that affects the
should be commenced as soon as possible, pref- flow of blood from the heart. Air may enter the
erably within one or two hours of the injury. circulation after injury, infusions into the ven-
Although PEP is available, safe systems of work ous circulation, or surgery. The victim suffers
are considered to offer the greatest protection. breathlessness, chest discomfort, and acute
Double-gloving (latex gloves remove much of heart failure.
the blood from the surface of the needle during
a needlestick), correct use of sharps containers Air Passages
(for used needles and instruments), avoiding These are the nose, pharynx or throat (the large
the resheathing of used needles, reduction in cavity behind the nose and mouth), larynx,
 22 Air-Sickness

trachea or windpipe, and bronchi or bronchial eyes is essential. In the tropics, light-induced
A tubes. On entering the nose, the air passes skin cancer may develop early.
through a high narrow passage on each side, the
outer wall of which has three projections (the Albumins
nasal conchae). It then passes down into the Albumins are water-soluble proteins which
pharynx where the food and air passages meet enter into the composition of all the tissues of
and cross. The larynx lies in front of the lower the body. Albumins are generally divided
part of the pharynx and is the organ where the according to their source of origin, as muscle-
voice is produced (see VOICE AND SPEECH) by albumin, milk-albumin, blood- or serum-
aid of the vocal cords. The opening between the albumin, egg-albumin, vegetable-albumin, etc.
cords is called the glottis, and shortly after These differ both in chemical reactions and also
passing this the air reaches the trachea or physiologically. Serum-albumin occurs in blood
windpipe. PLASMA where it is important in maintaining
The windpipe leads into the chest and div- plasma volume.
ides above the heart into two bronchi, one of When taken into the stomach, all albumins
which goes to each lung, in which it splits into are converted into a soluble form by the process
finer and finer tubes (see LUNGS). The larynx is of DIGESTION and then absorbed into the
enclosed in two strong cartilages: the thyroid blood, whence they go to build up the tissues.
(of which the most projecting part, the Adams Albumin is synthesised in the liver, and in
apple, is a prominent point on the front of the chronic liver disease this process is seriously
neck), and the cricoid (which can be felt as a affected. (See PROTEINURIA; KIDNEYS, DISEASES
hard ring about an inch below the thyroid). OF Glomerulonephritis.)
Beneath this, the trachea which is stiffened by
rings of cartilage so that it is never closed, no Albuminuria
matter what position the body is in can be See PROTEINURIA.
traced down until it disappears behind the
breastbone. Alcohol
A colourless liquid, also called ethanol or ethyl-
Air-Sickness alcohol, produced by the fermentation of car-
This condition is very similar to sea-sickness. bohydrates by yeast. Medically, alcohol is used
(See MOTION (TRAVEL) SICKNESS.) as a solvent and an antiseptic; recreationally it is
a widely used drug, taken in alcoholic drinks to
Akinesia give a pleasant taste as well as to relax, reduce
Loss or impairment of voluntary movement, or inhibitions, and increase sociability. Taken to
immobility. It is characteristically seen in excess, alcohol causes much mental and phys-
PARKINSONISM. ical harm not just to the individual imbibing
it, but often to their family, friends, community
Alastrim and work colleagues.
Alastrim, or variola minor, is a form of SMALL- Alcohol depresses the central nervous system
POX which differs from ordinary smallpox in and disturbs both mental and physical func-
being milder and having a low mortality. tioning. Even small doses of alcohol will slow a
persons reflexes and concentration; potentially
Albendazole dangerous effects when, for example, driving or
A drug adjunct to surgery in the treatment of operating machinery. Drunkenness causes
hydatid cysts (see under CYSTS) caused by Taenia slurred speech, muddled thinking, amnesia
echinococcus, a small tapeworm (see TAENIASIS). (memory loss), drowsiness, erectile IMPOTENCE,
If surgery is not possible, albendazole can be poor coordination and dulled reactions
used on its own. The drug is also used to treat thereby making driving or operating machinery
STRONGYLOIDIASIS. especially dangerous. Disinhibition may lead to
extreme euphoria, irritability, misery or aggres-
Albinism sion, depending on the underlying mood at the
A group of inherited disorders characterised by start of drinking. Severe intoxication may lead
absence of or decrease in MELANIN in the skin, to COMA and respiratory failure.
hair and eyes. The skin is pink, the hair white or Persistent alcohol misuse leads to physical,
pale yellow, and the iris of the eye translucent. mental, social and occupational problems, as
Nystagmus (see under EYE, DISORDERS OF), well as to a risk of DEPENDENCE (see also
PHOTOPHOBIA, SQUINT and poor eyesight are ALCOHOL DEPENDENCE). Misuse may follow
common. Photoprotection of both skin and several patterns: regular but controlled heavy
 Alcohol Dependence 23

intake, binge drinking, and dependence of wine or half-pint of beer a day. The social
(alcoholism). The first pattern usually leads to effects of alcohol misuse such as marital A
mainly physical problems such as gastritis, pep- breakdown, family violence and severe debt
tic ulcer, liver disease, heart disease and impo- can be equally devastating.
tence. The second is most common among Treatment of alcohol-related problems is
young men and usually leads to mainly social only moderately successful. First, many of the
and occupational problems getting into physical problems are treated in the short term
fights, jeopardising personal relationships, over- by doctors who fail to spot, or never ask about,
spending on alcohol at weekends, and missing heavy drinking. Second, attempts at treating
days off work because of hangovers. The third alcohol dependence by detoxification or drying
pattern alcohol dependence is the most ser- out (substituting a tranquillising drug for alco-
ious, and can severely disrupt health and social hol and withdrawing it gradually over about a
stability. week) are not always followed-up by adequate
Many researchers consider alcohol depend- support at home, so that drinking starts again.
ence to be an illness that runs in families, with a Home support by community alcohol teams
genetic component which is probably passed on comprising doctors, nurses, social workers and,
as a vulnerable personality. But it is hard to when appropriate, probation officers is a recent
disentangle genetic, environmental and social development that may have better results.
factors in such families. In the UK there are Many drinkers find the voluntary organisation
estimated to be around a million people suffer- Alcoholics Anonymous (AA) and its related
ing from alcohol dependence and a similar groups for relatives (Al-Anon) and teenagers
number who have difficulty controlling their (Alateen) helpful because total abstinence
consumption (together about 1:30 of the from alcohol is encouraged by intensive
population). psychological and social support from fellow
Alcohol causes tolerance and both physical ex-drinkers.
and psychological dependence (see DEPEND- Useful contacts are: Alcoholics Anonymous;
ENCE for definitions). Dependent drinkers clas- Al-Anon Family Groups UK and Eire (includ-
sically drink early in the morning to relieve ing Alateen); Alcohol Concern; Alcohol Focus
overnight withdrawal symptoms. These symp- Scotland; and Alcohol and Substance Misuse.
toms include anxiety, restlessness, nausea and
vomiting, and tremor. Sudden withdrawal from 1 standard drink = 1 unit
regular heavy drinking can lead to life- = pint of beer
threatening delirium tremens (DTs), with = 1 measure of spirits
severe tremor, hallucinations (often visual see- = 1 glass of sherry or vermouth
ing spiders and monsters, rather than the pink = 1 glass of wine
elephants of romantic myth), and CONVUL-
SIONS. This must be treated urgently with seda- Limits within which alcohol is believed not to
tive drugs, preferably by intravenous drip. cause long-term health risks:
Similar symptoms, plus severe INCOORDIN-
ATION and double-vision, can occur in WER- Women up to 2 units a day, 14 a week
NICKES ENCEPHALOPATHY, a serious neuro- (Pregnant women should avoid alcohol
logical condition due to lack of the B vitamin completely. If this is too difficult, 1 unit a day
thiamine (whose absorption from the stomach seems to be safe for the baby.) Women absorb
is markedly reduced by alcohol). If not alcohol more quickly than men.
treated urgently with injections of thiamine
and other vitamins, this can lead to an irrevers- Men up to 3 units a day, 21 a week
ible form of brain damage called Korsakoffs
psychosis, with severe amnesia. Finally, pro- Alcohol Dependence
longed alcohol misuse can cause a form of Alcohol dependence, or alcoholism, is
dementia. described under ALCOHOL but a summary of
In addition to these severe neurological dis- the symptoms may be helpful in spotting the
orders, the wide range of life-threatening prob- disorder. Behavioural symptoms vary but
lems caused by heavy drinking includes HEPA- include furtiveness; aggression; inappropriately
TITIS, liver CIRRHOSIS, pancreatitis (see PAN- generous gestures; personality changes (selfish-
CREAS, DISEASES OF), gastrointestinal haemor- ness, jealousy, irritability and outbursts of
rhage, suicide and FETAL ALCOHOL SYNDROME; anger); empty promises to stop drinking; poor
pregnant women should not drink alcohol as appetite; scruffy appearance; and long periods
this syndrome may occur with more than a glass of drunkenness.
 24 Alcuronium

A Alcuronium
the suprarenal, or adrenal, gland. Alkaloids are
Alcuronium is a drug which relaxes voluntary often used for medicinal purposes. The name of
muscles. Given by injection during ANAES- an alkaloid ends in ine (in Latin, ina).
THESIA to relax a patient undergoing surgery,
the drug may delay the restart of spontaneous Neutral principals are crystalline sub-
breathing. stances with actions similar to those of alkaloids
but having a neutral reaction. The name of a
Aldosterone neutral principal ends in in, e.g. digitalin,
Aldosterone is a hormone secreted by the aloin.
adrenal cortex (see ADRENAL GLANDS). It plays The following are the more important alkal-
an important part in maintaining the electro- oids, with their source plants:
lyte balance of the body by promoting the Aconite, from Monkshood.
reabsorption of sodium and the secretion of Atropine, from Belladonna (juice of Deadly
potassium by the renal tubules. It is thus of Nightshade).
primary importance in controlling the volume Cocaine, from Coca leaves.
of the body fluids. Hyoscine, from Henbane.
Morphine, Codeine, from Opium (juice of
Alexia Poppy).
Alexia is another name for WORD BLINDNESS. Thebaine, Nicotine, from Tobacco.
(See also APHASIA; DYSLEXIA.) Physostigmine, from Calabar beans.
Pilocarpine, from Jaborandi leaves.
Alfacalcidol Quinidine, from Cinchona or Peruvian bark.
Alfacalcidol is a synthetic form (or analogue) of Strychnine, from Nux Vomica seeds.
vitamin D. (See APPENDIX 5: VITAMINS.)
Alkalosis
Alglucerase Alkalosis means an increase in the alkalinity (see
A drug used under specialist supervision for the ALKALI) of the blood, or, more accurately, a
rare hereditary disorder, GAUCHERS DISEASE. decrease in the concentration of hydrogen ions
in the blood. It occurs, for example, in patients
Algorithm who have had large doses of alkalis for the
A set of instructions performed in a logical treatment of gastric ulcer. (See ACID BASE
sequence to solve a problem. Algorithms are BALANCE; ACIDOSIS.)
used increasingly in emergency situations, for
example by ambulance controllers or by organ- Alkaptonuria
isations such as NHS Direct. Each answer to a See OCHRONOSIS.
question leads on down a decision tree to the
next question, eventually resulting in a recom- Alkylating Agents
mended action or response. Alkylating agents are so named because they
alkylate or chemically react with certain bio-
Alimentary Canal chemical entities, particularly those concerned
See GASTROINTESTINAL TRACT. with the synthesis of NUCLEIC ACID. Alkylation
is the substitution of an organic grouping in
Alkali place of another grouping in a molecule.
A substance which neutralises an acid to form a Alkylating agents are important because they
salt, and turns litmus and other vegetable dyes interfere with the growth and reproduction of
blue. Alkalis are generally oxides or carbonates cells, disrupting their replication. This CYTO-
of metals. TOXIC property is used to retard the division
and growth of cancer cells, and alkylating drugs
Alkaloids are widely used in the chemotherapy of malig-
Substances found commonly in various plants. nant tumours often in conjunction with sur-
They are natural nitrogenous organic bases and gery and sometimes with radiotherapy.
combine with acids to form crystalline salts. Unfortunately, troublesome side-effects occur,
Among alkaloids, morphine was discovered in such as: damage to veins when the drug is given
1805, strychnine in 1818, quinine and caffeine intravenously, with resultant leakage into
in 1820, nicotine in 1829, and atropine in adjacent tissues; impaired kidney function due
1833. Only a few alkaloids occur in the animal to the formation of URIC ACID crystals; nausea
kingdom, the outstanding example being and vomiting; ALOPECIA (hair loss); suppression
ADRENALINE, which is formed in the medulla of of BONE MARROW activity (production of
 Allergy 25

blood cells); and adverse effects on repro- immunological response to an ALLERGEN, and
ductive function, including TERATOGENESIS. susceptibility has a strong genetic component. A
Indeed, cytotoxic drugs must not be given in Most allergic disorders are linked to ATOPY, the
pregnancy, especially during the first three predisposition to generate the allergic antibody
months. Prolonged use of alkylating drugs, immunoglobulin E (IgE) to common environ-
especially when accompanying radiotherapy, is mental agents (see ANTIBODIES; IMMUNO-
also associated with a signficant rise in the inci- GLOBULINS). Because IgE is able to sensitise
dence of acute non-lymphocytic LEUKAEMIA. MAST CELLS (which play a part in inflammatory
Among the dozen or so alkylating drugs in use and allergic reactions) anywhere in the body,
are CYCLOPHOSPHAMIDE, CHLORAMBUCIL, atopic individuals often have disease in more
MELPHALAN, BUSULFAN and THIOTEPA. (See also than one organ. Since the allergic disorder HAY
CHEMOTHERAPY.) FEVER was first described in 1819, allergy has
moved from being a rare condition to one
Allantoin afflicting almost one in two people in the
Prepared synthetically, this powder, which developed world, with substances such as grass
occurs naturally in comfrey root, has been used and tree pollen, house-dust mite, bee and wasp
as an ADJUVANT in the treatment of skin ulcers. venom, egg and milk proteins, peanuts, anti-
It has been thought to stimulate the formation biotics, and other airborne environmental pol-
of the surface epithelial layer of skin, but its lutants among the triggering factors. Increasing
therapeutic value is now more dubious. prevalence of allergic reactions has been notice-
able during the past two decades, especially in
Allantois young people with western lifestyles.
A vascular structure which, very early in the life A severe or life-threatening reaction is often
of an EMBRYO, grows out from its hind-gut. termed ANAPHYLAXIS. Many immune mechan-
The end becomes attached to the wall of the isms also contribute to allergic disorders; how-
womb (see UTERUS); it spreads out, becomes ever, adverse reactions to drugs, diagnostic
stalked, and later develops into the PLACENTA materials and other substances often do not
and umbilical cord, which forms the only con- involve recognised immunological mechanisms
nection between mother and embryo. and the term hypersensitivity is preferable. (See
also IMMUNITY.)
Allele Adverse reactions may manifest themselves as
An allele, or allelomorph, is a gene (see GENES) URTICARIA, wheezing or difficulty in breathing
which may exist in one or more forms, only one owing to spasm of the BRONCHIOLES, swollen
of which can occur in a given chromosome (see joints, nausea, vomiting and headaches. Severe
CHROMOSOMES). Two alleles of a given gene are allergic reactions may cause a person to go into
at the same relative positions on a pair of hom- SHOCK. Although symptoms of an allergic reac-
ologous (similarly structured) chromosomes. If tion can usually be controlled, treatment of the
the two alleles are identical, the subject is underlying conditon is more problematic:
homozygous for the gene namely, the genes hence, the best current approach is for suscep-
will exert a unanimous influence on a particular tible individuals to find out what it is they are
characteristic. If the alleles are different, with allergic to and avoid those agents. For some
one having a dominant and the other a recessive people, such as those sensitive to insect venom,
influence, the subject is heterozygous. IMMUNOTHERAPY or desensitisation is often
effective. If avoidance measures are unsuccessful
Allergen and desensitisation ineffective, the inflamma-
Any substance usually a protein which, tory reactions can be controlled with CORTICO-
taken into the body, makes the body hyper- STEROIDS, while the troublesome symptoms
sensitive or allergic to it. Thus, in hay fever, can be treated with ANTIHISTAMINE DRUGS and
the allergen is pollen. (See ALLERGY.) SYMPATHOMIMETICS. All three types of drugs
may be needed to treat severe allergic reactions.
Allergic Rhinitis One interesting hypothesis is that reduced
See HAY FEVER. exposure to infective agents, such as bacteria, in
infancy may provoke the development of
Allergy allergy in later life.
A term generally used to describe an adverse Predicted developments in tackling allergic
reaction by the body to any substance ingested disorders, according to Professor Stephen Hol-
by the affected individual. Strictly, allergy refers gate writing in the British Medical Journal (22
to any reactions incited by an abnormal January 2000) include:
 26 Allocheiria

A Identification of the principal environmental

factors underlying the increase in incidence,
as discoid lupus erythematosus (see under LUPUS)
or lichen planus (see under LICHEN) may cause
to enable preventive measures to be planned. patchy alopecia with scarring which is irrevers-
and
Safe and effective immunotherapy to prevent
reverse allergic disease.
ible. The long-term effects of radiotherapy may
be similar.
Treatments that target the protein reactions
activated by antigens. Treatment depends on the cause. Specific
Identification of how IgE is produced in the antifungal drugs cure tinea capitis. Correction
body, and thus of possible ways to inhibit of thyroid or iron deficiency may be dramatic.
this process. Male baldness may be modified slightly by
Identification of genes affecting peoples long-term use of minoxidil lotion, or improved
susceptibility to allergic disease. permanently by various types of hair-follicle
grafting of transplants from the occipital scalp.
Allocheiria Female balding may be amenable to anti-
The name for a disorder of sensation in which androgen/oestrogen regimens, but severe forms
sensations are referred to the wrong part of the require a wig.
body.
Alopecia Areata
Allograft Alopecia areata is a common form of reversible
A piece of tissue or an organ, such as the kidney, hair loss which may be patchy, total on the
transplanted from one to another of the same scalp, eyebrows or eyelashes, or universal on
species from person to person, for example. the body. The onset is sudden at any age and
Also known as a homograft. the affected scalp-skin looks normal. The hair
follicles remain intact but switched off and
Allopathy usually hair growth recovers spontaneously. No
A term applied sometimes by homeopaths consistently effective treatment is available
(see HOMEOPATHY) to the methods used by but injections of CORTICOSTEROIDS, given with
regular practitioners of medicine and surgery. a spray gun into the scalp, may be useful.
The term literally means curing by inducing a The regrown hair may be white at first but
different kind of action in the body, and is an pigmentation recovers later.
erroneous designation.
Alpha Adrenergic Blockers
Allopurinol Also called adrenoceptor-blocking agents or
A drug used to treat GOUT. It acts by suppress- alpha blockers, these drugs stop the stimula-
ing the formation of uric acid. It is also being tion of alpha-adrenergic receptors at the nerve
used in treatment of uric acid stone in the endings of the SYMPATHETIC NERVOUS SYS-
kidney. TEM by HORMONES with ADRENALINE-like
characteristics. The drugs dilate the arteries,
Alopecia causing a fall in blood pressure, so they are
Alopecia means hair loss. It may be localised or used to treat HYPERTENSION and also benign
total in the scalp. The commonest type, which enlargement of the PROSTATE GLAND.
is hereditary, is male baldness (androgenic alo- Examples of this group of drugs are doxa-
pecia). Female balding spares the anterior hair zosin, indoramin, phentolamine and prazosin.
line, develops later, and is less severe than the The drugs should be used with caution as
male variety. Diffuse hair loss is common after some may cause a severe drop in blood pres-
childbirth, severe illness or infection (telogen sure when first taken.
alopecia); it begins 812 weeks after the causa-
tive event and recovery is complete. Persistent Alpha-Feto Protein
diffuse hair loss may be caused by severe iron A protein produced in the gut and liver of the
deficiency or HYPOTHYROIDISM, or may be FETUS. Abnormality in the fetus, such as neural
drug-induced. tube defect, may result in raised levels of alpha-
Patchy localised hair loss is commonly caused feto protein in the maternal blood. In DOWNS
by fungal infections (tinea capitis see RING- (DOWN) SYNDROME, levels may be abnormally
WORM), especially in the tropics. It may also be low. In either case, screening of the pregnancy
due to trauma, such as hair-pulling by children should be carried out, including AMNIO-
or disturbed adults, or hair-straightening by CENTESIS to check the amount of alpha-feto
African or Afro-Caribbean women (traction protein in the amniotic fluid. The protein may
alopecia). Rarely, diseases of the scalp-skin such also be produced in some abnormal tissues in
 Alveolitis 27

the adult in patients with liver cancer, for Aluminium A

example. A light metallic element. It occurs in bauxite
and other minerals and its compounds are
ALTE found in low concentration in the body. Their
This is an abbreviation for acute life-threatening function, if any, is unknown but they are
event. It applies to infants, usually under one believed to be harmful. Aluminium hydroxide
year of age, who suddenly and unexpectedly is, however, a safe, slow-acting substance that is
become pale or blue and appear to stop breath- widely used in the treatment of indigestion,
ing. They generally recover spontaneously, gastric ulcers (see STOMACH, DISEASES OF) and
although a parent or bystander often adminis- oesophagitis (see OESOPHAGUS, DISEASES OF),
ters mouth-to-mouth resuscitation. By the time acting as an antacid (see ANTACIDS). Other
the baby reaches hospital he or she is usually ingested sources of aluminium include cooking
well. Investigations show that the most com- utensils, kitchen foil and some cooking and
mon cause of ALTE is GASTRO-OESOPHAGEAL food additives. Most aluminium is excreted;
REFLUX, causing stomach acid to be regurgi- the rest is deposited in the brain, liver, lungs
tated into the throat and provoking reflex clos- and thyroid gland. Prolonged use of
ure of the GLOTTIS. Other causes may be brief aluminium-based antacids can cause loss of
epileptic seizures, identified by ELECTRO- appetite, tiredness and weakness. It has been
ENCEPHALOGRAPHY (EEG); a heart ARRHYTH- suggested that ALZHEIMERS DISEASE is more
MIA; or a respiratory infection. In many cases common in areas with water which contains a
the cause remains unknown, even though the high concentration of the element, but this
events may be repeated, and the large major- issue is controversial.
ity of babies grow out of the condition.
Much controversy surrounds the suggestion Alveolitis
confirmed by hidden video-recording in hos- Inflammation of the alveoli (see ALVEOLUS) of
pitals that a small minority of these babies the lungs caused by an allergic reaction. When
have been subjected to repeated brief deliber- the inflammation is caused by infection it is
ate suffocation (see under MUNCHAUSENS called PNEUMONIA, and when by a chemical or
SYNDROME). physical agent it is called pneumonitis. It may
Treatment is that of the underlying cause, if be associated with systemic sclerosis or
discovered. Parents may also be offered an RHEUMATOID ARTHRITIS.
APNOEA monitor, a device attached to the child
especially when asleep which sounds an Extrinsic allergic alveolitis is the condi-
alarm if breathing stops for more than 20 tion induced by the lungs becoming allergic (see
seconds. ALLERGY) to various factors or substances. It
includes BAGASSOSIS, FARMERS LUNG and
Alternative Medicine BUDGERIGAR-FANCIERS LUNG, and is character-
See COMPLEMENTARY AND ALTERNATIVE MEDI- ised by the onset of shortness of breath, tight-
CINE (CAM). ness of the chest, cough and fever. The onset
may be sudden or gradual. Treatment consists
Altitude Sickness of removal of the affected individual from the
This condition, also known as mountain sick- offending material to which he or she has
ness, occurs in mountain climbers or hikers become allergic. CORTICOSTEROIDS give tem-
who have climbed too quickly to heights above porary relief.
3,000 metres, thus failing to allow their bodies
to acclimatise to altitude. The lower atmos- Fibrosing alveolitis In this disease there is
pheric pressure and shortage of oxygen result in diffuse FIBROSIS of the walls of the alveoli of the
hyperventilation deep, quick breathing and lungs. This causes loss of lung volume with
this reduces the amount of carbon dioxide in both forced expiratory volume and vital cap-
the blood. Nausea, anxiety and exhaustion are acity affected, but the ratio between them
presenting symptoms, and seriously affected remaining normal. The patient complains of
individuals may be acutely breathless because cough and progressive DYSPNOEA. Typically the
of pulmonary oedema (excess fluid in the patient will be cyanosed (blue see CYANOSIS),
lungs). Gradual climbing over two or three clubbed (see CLUBBING), and have crackles in
days should prevent mountain sickness. In the mid- and lower-lung fields. Blood gases will
serious cases the individual must be brought reveal HYPOXIA and, in early disease, hypocap-
down to hospital urgently. Most attacks, nia (deficiency of carbon dioxide in the blood
however, are mild. due to hyperventilation). There is an associ-
 28 Alveolus

ation with RHEUMATOID ARTHRITIS (about nerve cells (developed from stem cells) into
A one-eighth of cases), systemic lupus erythema- the brain tissue of patients with Alzheimers
tosus (see under LUPUS), and systemic SCLEROSIS. disease with the aim of improving brain
Certain drugs for example, bleomycin, function.
busulphan and hexamethonium may also The rising proportion of elderly people in
cause this condition, as may high concentra- the population is resulting in a rising incidence
tions of oxygen, and inhalation of CADMIUM of Alzheimers, which is rare before the age of
fumes. 60 but increases steadily thereafter so that 30
per cent of people over the age of 84 are
Alveolus affected.
(1) The minute divisions of glands and the air
sacs of the lungs. Amantadine
(2) The sockets of the teeth in the jawbone. A drug used to treat certain virus infections
which is also of value in the prevention of some
Alzheimers Disease forms of influenza. It is also used to treat
Alzheimers disease is a progressive degenerating PARKINSONISM.
process of neural tissue affecting mainly the
frontal and temporal lobes of the BRAIN in Amaurosis Fugax
middle and late life. There is probably a genetic Sudden transitory impairment, or loss, of
component to Alzheimers disease, but early- vision. It usually affects only one eye, and is
onset Alzheimers is linked to certain muta- commonly due to circulatory failure. In its sim-
tions, or changes, in three particular GENES. plest form it occurs in normal people on rising
Examination of affected brains shows senile suddenly from the sitting or recumbent pos-
plaques containing an amyloid-like material ition, when it is due to the effects of gravity. It
distributed throughout an atrophied cortex (see also occurs in migraine. A not uncommon
AMYLOID PLAQUES). Many remaining neurons,
cause, particularly in elderly people, is transient
or nerve cells, show changes in their NEUROFI- ocular ISCHAEMIA, resulting from blockage of
BRILS which thicken and twist into neurofibril-
the circulation to the retina (see EYE) by emboli
lary tangles. First symptoms are psychological (see EMBOLISM) from the common carotid
with insidious impairment of recent memory artery or the heart. Treatment in this last group
and disorientation in time and space. This of cases consists of control of the blood pressure
becomes increasingly associated with difficulties if this is raised, as it often is in such cases; and
in judgement, comprehension and abstract rea- the administration of drugs that reduce the
soning. After very few years, progressive neuro- stickiness of blood platelets, such as aspirin. In
logical deterioration produces poor gait, some instances, removal of the part of the
immobility and death. When assessment has carotid artery from which the emboli are com-
found no other organic cause for an affected ing may be indicated.
individuals symptoms, treatment is primarily
palliative. The essential part of treatment is the
provision of appropriate nursing and social care, Ambivalence
with strong support being given to the relatives The psychological state in which a person con-
or other carers for whom looking after sufferers currently hates and loves the same object or
is a prolonged and onerous burden. Proper diet person.
and exercise are helpful, as is keeping the indi-
vidual occupied. If possible, sufferers should Amblyopia
stay in familiar surroundings with day-care and Defective vision for which no recognisable
short-stay institutional facilities a useful way of cause exists in any part of the eye. It may be due
maintaining them at home for as long as to such causes as defective development or
possible. excessive use of tobacco or alcohol. The most
TRANQUILLISERS can help control difficult important form is that associated with SQUINT,
behaviour and sleeplessness but should be or gross difference in refraction between the
used with care. Recently drugs such as two eyes. It has been estimated that in Britain
DONEPEZIL and RIVASTIGMINE, which retard around 5 per cent of young adults have ambly-
the breakdown of ACETYLCHOLINE, may check opia due to this cause.
but not cure this distressing condition.
About 40 per cent of those with DEMENTIA Amelia
improve. This is absence of the limbs, usually a con-
Research is in progress to transplant healthy genital defect.
 Aminocaproic Acid 29

Amenorrhoea Amentia A
Absence of MENSTRUATION at the time of life at Amentia is the failure of the intellectual facul-
which it should normally occur. If menstru- ties to develop normally.
ation has never occurred, the amenorrhoea is
termed primary; secondary amenorrhoea is Amethocaine
defined as menstruation ceasing after a normal An effective local anaesthetic for topical appli-
cycle has been experienced for a number of cation. Rapidly absorbed from mucous mem-
years. branes, it should never be applied to inflamed,
A few patients with primary amenorrhoea traumatised or highly vascular surfaces nor
have an abnormality of their CHROMOSOMES or used when providing anaesthesia for bron-
malformation of the genital tract such as abse- choscopy or cystoscopy. Amethocaine is used in
cence of the UTERUS (see TURNERS SYNDROME). ophthalmology and in skin preparations. It may
A gynaecological examination will rarely dis- sensitise the skin. (See ANAESTHESIA.)
close an IMPERFORATE HYMEN in a young girl
who may also complain of regular cycles of pain Ametropia
like period pains. See REFRACTION.
There are many causes of secondary amen-
orrhoea and management requires dealing Amikacin
with the primary cause. The commonest One of the AMINOGLYCOSIDES, amikacin is a
cause is pregnancy. Disorders of the HYPO- semi-synthetic derivative of KANAMYCIN, which
THALAMUS and related psychological factors is used to treat infections caused by micro-
such as anorexia nervosa (see EATING DIS- organisms resistant to GENTAMICIN and
ORDERS) also cause amenorrhoea, as can poor TOBRAMYCIN.
nutrition and loss of weight by extreme diet-
ing. It is common in ballet dancers and ath- Amiloride
letes who exercise a great deal, but can also be A diuretic that acts without causing excessive
triggered by serious illnesses such as tubercu- loss of potassium (see DIURETICS).
losis or malaria. Excess secretion of prolactin,
either due to a micro-adenoma (see ADENOMA) Amines
of the PITUITARY GLAND or to various pre- Substances derived from ammonia or AMINO
scription drugs will produce amenorrhoea, ACIDS which play an important part in the
and sometimes GALACTORRHOEA as well. Mal- working of the body, including the brain and
function of other parts of the pituitary gland the circulatory system. They include ADRENA-
will cause failure to produce GONADO- LINE, NORADRENALINE and HISTAMINE. (See
TROPHINS, thus causing ovarian failure with also MONOAMINE OXIDASE INHIBITORS
consequent amenorrhea. In CUSHINGS SYN- (MAOIS).)
DROME, amenorrhoea is caused by excessive
production of cortisol. Similarly, androgen- Amino Acids
production abnormalities are found in the Chemical compounds that are the basic
common POLYCYSTIC OVARY SYNDROME. building-blocks of all proteins. Each molecule
These conditions also have abnormalities of consists of nitrogenous amino and acidic carb-
the insulin/glucose control mechanisms. Tak- oxyl groups of atoms joined to a group of car-
ing the contraceptive pill is not now con- bon atoms. Polypeptides are formed by amino-
sidered to provoke secondary amenorrhoea but acid molecules linking via peptide bonds.
OBESITY and HYPOTHYROIDISM are potential Many polypeptides link up in various con-
causes. figurations to form protein molecules. In
When the cause is weight loss, restoring body humans, proteins are made up from 20 differ-
weight may alone restore menstruation. ent amino acids: nine of these are labelled
Otherwise, measuring gonadotrophic hormone essential (or, as is now preferred, indispens-
levels will help show whether amenorrhoea is able) amino acids because the body cannot
due to primary ovarian failure or secondary to manufacture them and is dependent on the
pituitary disease. Women with raised concen- diet for their provision. (See also INDISPENSABLE
trations of serum gonadotrophic hormones AMINO ACIDS.)
have primary ovarian failure. When amenor-
rhoea is due to limited pituitary failure, treat- Aminocaproic Acid
ment with CLOMIPHENE may solve the A drug used to treat hereditary angio-oedema
problem. (see under URTICARIA) a serious anaphylactic
(see ANAPHYLAXIS) reaction of the skin and
 30 Aminoglutethimide

respiratory tract resulting from a deficiency in

A the bodys immunological defence mechanisms Amnesia
Amnesia means loss of memory.
(see IMMUNITY).
Amniocentesis
Aminoglutethimide A diagnostic procedure for detecting abnormal-
A drug that inhibits the synthesis of adrenal ities of the FETUS. Usually carried out between
CORTICOSTEROIDS. It is proving to be of value the 16th and 18th week of pregnancy, amnio-
in the treatment of cancer of the breast in centesis is performed by piercing the amniotic
post-menopausal women. sac in the pregnant UTERUS with a hollow
needle and withdrawing a sample of AMNIOTIC
Aminoglycosides FLUID for laboratory analysis. As well as check-
A group of antibiotics usually reserved for use ing for the presence of abnormal fetal cells, the
in patients with severe infections. They are procedure can show the sex of the fetus. The
effective against a wide range of BACTERIA risk of early rupture of the fetal membranes or
including some gram-positive and many of miscarriage is low (around 0.5 per cent).
gram-negative organisms (see GRAMS STAIN).
Aminoglycosides must be used cautiously Amnion
because they can damage the inner ear thus Amnion is the tough fibrous membrane which
affecting hearing and the kidneys. Examples lines the cavity of the womb (UTERUS) during
of this group are AMIKACIN and GENTAMICIN pregnancy, and contains between 05 and 1 litre
(effective against Pseudomonas aeuriginosa), (12 pints) of fluid in which the EMBRYO floats.
NEOMYCIN (used only for topical administra- It is formed from the ovum (egg) along with the
tion for skin infections), and STREPTOMYCIN embryo, and in labour the part of it at the
(effective in combination with other drugs mouth of the womb forms the bag of waters.
against Mycobacterium tuberculosis). (See PREGNANCY AND LABOUR.) When a child is
born with a CAUL, the caul is a piece of
Aminophylline amnion.
A combination of theophylline and ethylenedi-
amine. It is used intravenously in the treatment Amnioscopy
of acute severe ASTHMA, or as an oral prepar- The insertion of a viewing instrument (amnio-
ation in the treatment of chronic asthma. scope) through the abdominal wall into the
pregnant UTERUS to examine the inside of the
Amiodarone amniotic sac (see AMNION). The growing FETUS
(in the form of amiodarone hydrochloride) is a can be viewed directly and its condition and sex
drug used to treat ARRHYTHMIA of the HEART assessed without disturbing the pregnancy. The
and initiated only under supervision in hos- amniotic sac may also be viewed late in preg-
pital or by an appropriate specialist. Given by nancy through the cervix or neck of the womb
mouth or intravenous infusion, amiodarone using an instrument called the fetoscope.
can help to control paroxysmal supraventricu-
lar, nodal and ventricular TACHYCARDIA as well Amniotic Fluid
as FIBRILLATION of the auricles and ventricles The clear fluid contained within the AMNION
of the heart. It may take some time to achieve that surrounds the FETUS in the womb and pro-
control, and several weeks to be eliminated tects it from external pressure. The fluid, com-
from the body when treatment is stopped. The prising mainly water, is produced by the
drug has a range of potentially serious side- amnion and is regularly circulated, being swal-
effects. lowed by the fetus and excreted through the
kidneys back into the amniotic sac. By the 35th
Amitriptyline week of pregnancy there is about 1 litre of fluid,
See ANTIDEPRESSANT DRUGS. but this falls to 0.5 litres at term. The amniotic
sac normally ruptures in early labour, releasing
Ammonia the fluid or waters.
A compound of hydrogen and nitrogen that
occurs naturally. The solution is colourless with Amniotic Sac
a pungent smell; it is used in urine testing. In See AMNION.
humans, certain inherited defects in the metab-
olism of ammonia can cause neurological symp- Amoeba
toms including mental retardation. In vapour A minute protozoan organism consisting of a
form it is a noxious gas. single cell, in which a nucleus is surrounded by
 Amputation 31

protoplasm that changes its shape as the proto- Ampoule A

zoon progresses or absorbs nourishment. Sev- A small glass container having one end drawn
eral varieties are found under different condi- out into a point capable of being sealed so as to
tions within the human body. One variety, preserve its contents sterile. It is used for con-
Entamoeba coli, is found in the large intestine of taining solutions for hypodermic injection.
humans without any associated disease;
another, Entamoeba gingivalis, is found in the Ampulla of Vater
sockets of the teeth and associated with PYOR- The dilated section of the common BILE DUCT
RHOEA. Entamoeba histolytica is the causative
when it is joined by the duct from the
organism of amoebic dysentery (see DYS- PANCREAS.
ENTERY); Acanthamoeba and Naegleria fowleri
cause the infection of the brain known as
MENINGOENCEPHALITIS. Entamoeba histolytica
Amputation
may also cause meningoencephalitis. Other Severance of a limb, or part of a limb, from the
forms are found in the genital organs. rest of the body. The leg is the most common
site of amputation. It is usually performed as a
controlled operation and may be required for a
Amoebiasis variety of reasons. In the young, severe injury is
See DYSENTERY.
the most common cause, when damage to
the limb is so extensive as to make it non-viable
Amoxicillin or functionally useless. In the elderly, amputa-
See PENICILLIN; ANTIBIOTICS.
tion is more often the result of vascular insuffi-
ciency, resulting in gangrene or intractable pain.
Amphetamines
A group of drugs closely related to ADRENALINE
which act by stimulating the SYMPATHETIC
NERVOUS SYSTEM. When taken by mouth they
have a profound stimulating effect on the brain,
producing a sense of well-being and confidence
and seemingly increasing the capacity for men-
tal work. They are, however, drugs of DEPEND-
ENCE and their medical use is now strictly
limited for example, to the treatment of
NARCOLEPSY.
Because amphetamines inhibit appetite, they
rapidly achieved a reputation for slimming pur-
poses. However, they should not be used for
this purpose; their dangers far outweigh their
advantages.

Amphoric
An adjective denoting the kind of breathing
heard over a cavity in the lung. The sound is
like that made by blowing over the mouth of a
narrow-necked vase.

Amphotericin
A highly toxic, polygenic antifungal drug that
must be given only under close medical supervi-
sion and for severe systemic fungal infections
(see FUNGAL AND YEAST INFECTIONS). It is not
absorbed from the gut so is normally given par-
enterally (see PARENTERAL). Oral and intestinal
candidiasis (see CANDIDA) can, however, be
treated with amphotericin tablets.

Ampicillin
See PENICILLIN; ANTIBIOTICS. Amputation sites of lower limb.
 32 Amsacrine

Sarcoma (see CANCER) of bone, muscle or con-

A nective tissues in a limb is another reason for Amyotrophy
Loss of muscle bulk and strength caused by a
amputation. disorder of the nerve that supplies the muscle.
The aim is to restore the patient to full The loss is progressive and characterises chronic
mobility with a prosthetic (artificial) limb, NEUROPATHY. Patients with DIABETES MEL-
which requires both a well-fitting PROSTHESIS LITUS and MOTOR NEURONE DISEASE (MND)
and a well-healed surgical wound. If this is not often suffer from amyotrophy as well as spas-
possible, the aim is to leave the patient with a ticity (see SPASTIC) of muscles.
limb stump that is still useful for balancing,
sitting and transferring. Common types of
lower-limb amputation are shown in the illus- Anabolic Steroids
tration. The Symes amputation can be walked The nitrogen-retaining effect of ANDROGEN, a
upon without requiring a prosthesis. The steroid hormone, is responsible for the larger
below-knee amputation preserves normal flex- muscle mass of the male. This is called an
ion of the knee, and virtually normal walking anabolic effect. Attempts have been made to
can be achieved with a well-fitting artificial separate the anabolic effects of hormones from
limb. Learning to walk is more difficult follow- their virilising effects (see VIRILISATION), but
ing an above-knee amputation, but some these have been only partially successful. Thus,
highly motivated patients can manage well. anabolic steroids have the property of protein-
After any amputation it is not unusual for the building so that when taken, they lead to an
patient to experience the sensation that the increase in muscle bulk and strength. All the
limb is still present: this is called a PHANTOM anabolic steroids have some androgenic activ-
LIMB and the sensation may persist for a long ity but they cause less virilisation than andro-
time. gens in women. Androgenic side-effects may
result from any of these anabolic compounds,
Amsacrine especially if they are given for prolonged
See under CYTOTOXIC. periods: for this reason they should all be used
with caution in women, and are contraindi-
Amylase cated in men with prostatic carcinoma. Jaun-
An ENZYME in pancreatic juice which facilitates dice due to stasis of bile in the intrahepatic
the conversion of starch to maltose. (See canaliculi is a hazard, and the depression of
PANCREAS.) pituitary gonadotrophin production is a pos-
sible complication.
Amyl Nitrite Anabolic steroids have been used to stimulate
A volatile, oily liquid prepared by the action of protein anabolism in debilitating illness, and to
nitric and nitrous acids on amyl alcohol. It was promote growth in children with pituitary
used for many years to treat angina but has been dwarfism and other disorders associated with
superseded by other nitrate drugs such as interference of growth. Stimulation of protein
glyceril trinitrate. The substance is misused by anabolism may also be of value in acute renal
drug abusers to produce a high and is referred failure, and the retention of nitrogen and cal-
to as poppers. cium is of probable benefit to patients with
OSTEOPOROSIS and to patients receiving corti-
Amyloidosis costeroid therapy. Anabolic steroids may stimu-
A rare condition in which deposits of complex late bone-marrow function in hypoplastic
protein, known as amyloid, are found in various ANAEMIA.
parts of the body. It is a degenerative condition They have been widely abused by athletes
resulting from various causes such as chronic and body-builders aiming to improve their
infection, including tuberculosis and rheuma- strength, stamina, speed or body size. However,
toid arthritis. there are considerable doubts over their efficacy,
with little experimental evidence that they
Amyloid Plaques work. Dangerous adverse effects include preco-
Characteristic waxy deposits of amyloid found cious myocardial infarction (see HEART, DIS-
in primary AMYLOIDOSIS, the cause of which is EASES OF Coronary thrombosis), DIABETES
unknown. MELLITUS, liver disease, precocious carcinoma
of the prostate, acne, and severe psychiatric dis-
Amylose orders. Anabolic steroids should not be used by
The name applied to any carbohydrate of the athletes, who face bans from official competi-
starch group. tions if they take them.
 Anaemia 33

The anabolic steroids in therapeutic use

include nandrolone and stanozolol.
Bleeding from the gastrointestinal tract. The
best example here is anaemia due to bleeding A
piles (see HAEMORRHOIDS). Such bleeding,
Anabolism even though slight, is a common cause of
Production by the body of complex molecules anaemia in both men and women if main-
like fat and proteins from simpler substances tained over a long period of time. The haem-
taken in the diet. orrhage may be more acute and occur from a
DUODENAL ULCER or gastric ulcer (see STOM-
Anaemia ACH, DISEASES OF), when it is known as
The condition characterised by inadequate red haematemesis.
blood cells and/or HAEMOGLOBIN in the Certain blood diseases, such as PURPURA and
BLOOD. It is considered to exist if haemoglobin HAEMOPHILIA, which are characterised by
levels are below 13 grams per 100 ml in males bleeding.
and below 12 grams per 100 ml in adult non-
pregnant women. No simple classification of DEFECTIVE BLOOD FORMATION
anaemia can be wholly accurate, but the most
useful method is to divide anaemias into: (a)
This is the main cause of anaemia in infec-
tions. The micro-organism responsible for
microcytic hypochromic or iron deficiency the infection has a deleterious effect upon the
anaemia; (b) megaloblastic hyperchromic blood-forming organs, just as it does upon
anaemia; (c) aplastic anaemia; (d) haemolytic other parts of the body.
anaemia; (e) inherited anaemias (see below).
In Britain, anaemia is much more common
Toxins. In conditions such as chronic
glomerulonephritis (see KIDNEYS, DISEASES
among women than men. Thus, around 10 per OF) and URAEMIA there is a severe anaemia
cent of girls have anaemia at the age of 15, due to the effect of the disease upon blood
whilst in adult life the incidence is over 30 per formation.
cent between the ages of 30 and 40, around 20
per cent at 50, and around 30 per cent at 70.
Drugs. Certain drugs, such as aspirin and the
non-steroidal anti-inflammatory drugs, may
Among men the incidence is under 5 per cent cause occult gastrointestinal bleeding.
until the age of 50; it then rises to 20 per cent at
the age of 70. Ninety per cent of all cases of INADEQUATE ABSORPTION OF IRON
anaemia in Britain are microcytic, 7 per cent are
This may occur in diseases of intestinal
macrocytic, and 3 per cent are haemolytic or
malabsorption. A severe form of this anaemia in
aplastic. Inherited anaemias include sickle-cell
women, known as chlorosis, used to be com-
anaemia and THALASSAEMIA.
mon but is seldom seen nowadays.
Microcytic hypochromic anaemia
corresponds to a large extent with what used to INADEQUATE INTAKE OF IRON
be known as secondary anaemia. It takes its The daily requirement of iron for an adult is 12
name from the characteristic changes in the mg, and 1520 mg for an adult woman during
blood. pregnancy. This is well covered by an ordinary
diet, so that by itself it is not a common cause.
Causes But if there is a steady loss of blood, as a result
LOSS OF BLOOD of heavy menstrual loss or bleeding piles, the
As a result of trauma. This is perhaps the
simplest example of all, when, as a result of
intake of iron in the diet may not be sufficient
to maintain adequate formation of
an accident involving a large artery, there is haemoglobin.
severe haemorrhage.
Menstruation. The regular monthly loss of
blood which women sustain as a result of
Symptoms These depend upon whether the
anaemia is sudden in onset, as in severe haem-
menstruation always puts a strain on the orrhage, or gradual. In all cases, however, the
blood-forming organs. If this loss is excessive, striking sign is pallor, the depth of which
then over a period of time it may lead to depends upon the severity of the anaemia. The
quite severe anaemia. colour of the skin may be misleading, except in
Childbirth. A considerable amount of blood
is always lost at childbirth; if this is severe, or
cases due to severe haemorrhage, as the skin of
many Caucasian people is normally pale. The
if the woman was anaemic during preg- best guide is the colour of the internal lining of
nancy, a severe degree of anaemia may the eyelid. When the onset of the anaemia is
develop. sudden, the patient complains of weakness and
 34 Anaemia

giddiness, and loses consciousness if he or she tion in the terminal part of the ILEUM. Lack of
A tries to stand or sit up. The breathing is rapid the factor prevents vitamin B12 absorption and
and distressed, the pulse is rapid and the blood this causes macrocytic (or megaloblastic)
pressure is low. In chronic cases the tongue is anaemia. The disorder can affect men and
often sore (GLOSSITIS), and the nails of the fin- women, usually those over the age of 40; onset
gers may be brittle and concave instead of con- is insidious so it may be well advanced before
vex (koilonychia). In some cases, particularly in medical advice is sought. The skin and
women, the Plummer-Vinson syndrome is MUCOSA become pale, the tongue is smooth
present: this consists of difficulty in swallow- and atrophic and is accompanied by CHEILO-
ing and may be accompanied by huskiness; in SIS. Peripheral NEUROPATHY is often present,
these cases glossitis is also present. There resulting in PARAESTHESIA and numbness and
may be slight enlargement of the SPLEEN, and sometimes ATAXIA. A rare complication is sub-
there is usually some diminution in gastric acute combined degeneration of the SPINAL
acidity. CORD.
In 1926 two Americans, G R Minot and W
CHANGES IN THE BLOOD The characteristic P Murphy, discovered that pernicious anaemia,
change is a diminution in both the haemo- a previously fatal condition, responded to
globin and the red cell content of the blood. treatment with liver which provides the absent
There is a relatively greater fall in the haemo- intrinsic factor. Normal development requires a
globin than in the red cell count. If the blood is substance known as extrinsic factor, and this
examined under a microscope, the red cells are depends on the presence of intrinsic factor for
seen to be paler and smaller than normal. These its absorption from the gut. The disease is char-
small red cells are known as microcytes. acterised in the blood by abnormally large red
cells (macrocytes) which vary in shape and size,
Treatment consists primarily of giving suf- while the number of white cells (LEUCOCYTES)
ficient iron by mouth to restore, and then main- diminishes. A key diagnostic find is the pres-
tain, a normal blood picture. The main iron ence of cells in the BONE MARROW.
preparation now used is ferrous sulphate, 200
mg, thrice daily after meals. When the blood Treatment consists of injections of vitamin
picture has become normal, the dosage is grad- B12 in the form of hydroxocobalamin which
ually reduced. A preparation of iron is available must be continued for life.
which can be given intravenously, but this is
only used in cases which do not respond to iron Aplastic anaemia is a disease in which the
given by mouth, or in cases in which it is essen- red blood corpuscles are very greatly reduced,
tial to obtain a quick response. and in which no attempt appears to be made in
If, of course, there is haemorrhage, this must the bone marrow towards their regeneration. It
be arrested, and if the loss of blood has been is more accurately called hypoplastic anaemia as
severe it may be necessary to give a blood trans- the degree of impairment of bone-marrow
fusion (see TRANSFUSION Transfusion of function is rarely complete. The cause in many
blood). Care must be taken to ensure that the cases is not known, but in rather less than half
patient is having an adequate diet. If there is the cases the condition is due to some toxic
any underlying metabolic, oncological, toxic substance, such as benzol or certain drugs, or
or infective condition, this, of course, must ionising radiations. The patient becomes very
be adequately treated after appropriate pale, with a tendency to haemorrhages under
investigations. the skin and mucous membranes, and the tem-
perature may at times be raised. The red blood
Megaloblastic hyperchromic anae- corpuscles diminish steadily in numbers.
mia There are various forms of anaemia of Treatment consists primarily of regular blood
this type, such as those due to nutritional transfusions. Although the disease is often fatal,
deficiencies, but the most important is that the outlook has improved in recent years:
known as pernicious anaemia. around 25 per cent of patients recover when
adequately treated, and others survive for sev-
PERNICIOUS ANAEMIA An autoimmune disease eral years. In severe cases promising results are
in which sensitised lymphocytes (see LYMPHO- being reported from the use of bone-marrow
CYTE) destroy the PARIETAL cells of the stom- transplantation.
ach. These cells normally produce INTRINSIC
FACTOR, the carrier protein for vitamin B12 (see Haemolytic anaemia results from the
APPENDIX 5: VITAMINS) that permits its absorp- excessive destruction, or HAEMOLYSIS, of the red
 Anaesthesia 35

blood cells. This may be the result of undue a state of reversible UNCONSCIOUSNESS. Bal-
fragility of the red blood cells, when the condi- anced anaesthesia uses a combination of drugs A
tion is known as congenital haemolytic to provide unconsciousness, analgesia, and a
anaemia, or of acholuric JAUNDICE. greater or lesser degree of muscle relaxation.
A general anaesthetic comprises induction,
Sickle-cell anaemia A form of anaemia maintenance and recovery. Historically, anaes-
characteristically found in people of African thesia has been divided into four stages (see
descent, so-called because of the sickle shape of below), but these are only clearly seen during
the red blood cells. It is caused by the presence induction and maintenance of anaesthesia
of the abnormal HAEMOGLOBIN, haemoglobin using inhalational agents alone.
S, due to AMINO ACID substitutions in their (1) Onset of induction to unconsciousness
polypeptide chains, reflecting a genetic muta- (2) Stage of excitement
tion. Deoxygenation of haemoglobin S leads to (3) Surgical anaesthesia
sickling, which increases the blood viscosity and (4) Overdosage
tends to obstruct flow, thereby increasing the Induction involves the initial production of
sickling of other cells. THROMBOSIS and areas of unconsciousness. Most often this is by INTRA-
tissue INFARCTION may follow, causing severe VENOUS injection of a short-acting anaesthetic
pain, swelling and tenderness. The resulting agent such as PROPOFOL, THIOPENTONE or
sickle cells are more fragile than normal red ETOMIDATE, often accompanied by additional
blood cells, and have a shorter life span, hence drugs such as ANALGESICS to smooth the pro-
the anaemia. Advice is obtainable from the cess. Alternatively an inhalational technique
Sickle Cell Society. may be used.
Maintenance of anaesthesia may be provided
Anaerobe by continuous or intermittent use of intraven-
The term applied to bacteria having the power ous drugs, but is commonly provided by
to live without air. Such organisms are found administration of OXYGEN and NITROUS OXIDE
growing freely, deep in the soil as, for or air containing a volatile anaesthetic agent.
example, the tetanus bacillus. Anaesthetic machines are capable of providing a
constant concentration of these, and have fail-
Anaesthesia safe mechanisms and monitors which guard
The loss or absence of sensation or feeling. against the patients receiving a gas mixture
Commonly used to describe a reversible process with inadequate oxygen (see HYPOXIC). The
which allows operations and painful or gases are adminstered to the patient via a
unpleasant procedures to be performed without breathing circuit either through a mask, a
distress to the patient. laryngeal mask or via ENDOTRACHEAL INTUB-
The speciality of anaesthesia broadly covers ATION. In recent years, concerns about side-
its provision for SURGERY, intensive therapy effects and pollution caused by volatile agents
(intensive care), chronic pain management, have led to increased popularity of total intra-
acute pain management and obstetric venous anaesthesia (TIVA).
analgesia. Anaesthetists in Britain are trained For some types of surgery the patient is para-
specialists with a medical degree, but in many lysed using muscle relaxants and then artificially
countries some anaesthetists may be nurse prac- ventilated by machine (see VENTILATOR).
titioners working under the supervision of a Patients are closely monitored during anaes-
medical anaesthetist. thesia by the anaesthetist using a variety of
The anaesthetist will assess the patients fit- devices. Minimal monitoring includes ELEC-
ness for anaesthesia, choose and perform the TROCARDIOGRAM (ECG), blood pressure, PULSE
appropriate type of anaesthetic while monitor- OXIMETRY, inspired oxygen and end-tidal
ing and caring for the patients well-being, and, carbon-dioxide concentration the amount of
after the anaesthetic, supervise recovery and the carbon dioxide breathed out when the lungs are
provision of post-operative pain relief. at the empty stage of the breathing cycle.
Anaesthesia may be broadly divided into Analgesic drugs (pain relievers) and local or
general and local anaesthesia. Quite commonly regional anaesthetic blocks are often given to
the two are combined to allow continued relief supplement general anaesthesia.
of pain at the operation site after the patient Volatile anaesthetics are either halogenated
awakens. hydrocarbons (see HALOTHANE) or halogenated
ethers (isoflurane, enflurane, desflurane and
General anaesthesia is most often pro- sevoflurane). The latter two are the most
duced by using a combination of drugs to induce recently introduced agents, and produce the
 36 Anaesthesia

Patient under general anaesthesia (top). Use of a mask to deliver anaesthetic gases (bottom left). Deliver-
ing anaesthetic gases direct to the lungs (bottom right).

most rapid induction and recovery though on reversal or recovery phase of anaesthesia. Once
a worldwide basis halothane, ether and chloro- the anaesthetist is satisfied with the degree of
form are still widely used. recovery, patients are transferred to a recovery
Despite several theories, the mode of action area within the operating-theatre complex
of these agents is not fully understood. Their where they are cared for by specialist staff,
efficacy is related to how well they dissolve into under the supervision of an anaesthetist, until
the LIPID substances in nerve cells, and it is they are ready to return to the ward. (See also
thought that they act at more than one site ARTIFICIAL VENTILATION OF THE LUNGS.)
within brain cells probably at the cell mem-
brane. By whatever method, they reversibly Local anaesthetics are drugs which revers-
depress the conduction of impulses within the ibly block the conduction of impulses in nerves.
CENTRAL NERVOUS SYSTEM and thereby pro- They therefore produce anaesthesia (and muscle
duce unconsciousness. relaxation) only in those areas of the body
At the end of surgery any muscle relaxant still served by the nerve(s) affected by these drugs.
in the patients body is reversed, the volatile Many drugs have some local anaesthetic action
agent is turned off and the patient breathes but the drugs used specifically for this purpose
oxygen or oxygen-enriched air. This is the are all amide or ester derivatives of aromatic
 Analgesics 37

acids. Variations in the basic structure produce plications include hypotension, spinal headache
drugs with different speeds of onset, duration of (less than 1:100), poor efficacy, nerve damage A
action and preferential SENSORY rather than (1:12,000) and spinal-cord compression from
MOTOR blockade (stopping the activity in the CLOT or ABSCESS (extremely rare).
sensory or motor nerves respectively).
The use of local rather than general anaes- Analeptic
thesia will depend on the type of surgery and in A restorative medicine, or one which acts as a
some cases the unsuitability of the patient for stimulant of the central nervous system: for
general anaesthesia. It is also used to supple- example, caffeine.
ment general anaesthesia, relieve pain in labour
(see under PREGNANCY AND LABOUR) and in the Analgesia
treatment of pain in persons not undergoing See ANALGESICS; PAIN.
surgery. Several commonly used techniques are
listed below: Analgesics
Drugs which relieve or abolish PAIN. Unlike
LOCAL INFILTRATION An area of anaesthetised local anaesthetics, they are usually given sys-
skin or tissue is produced by injecting local temically affecting the whole body and
anaesthetic around it. This technique is used for produce no SENSORY or MOTOR blockade
removing small superficial lesions or anaesthe- stopping the activity in the sensory or motor
tising surgical incisions. nerves respectively that supply a part of the
body. The many different types of analgesics
NERVE BLOCKS Local anaesthetic is injected have varying modes of action. The choice of
close to a nerve or nerve plexus, often using a drug and method of administration will
peripheral nerve stimulator to identify the cor- depend upon the type and severity of pain
rect point. The anaesthetic diffuses into the being treated.
nerve, blocking it and producing anaesthesia in Non-opioid analgesics include ASPIRIN,
the area supplied by it. PARACETAMOL and NON-STEROIDAL ANTI-
INFLAMMATORY DRUGS (NSAIDS), which are
SPINAL ANAESTHESIA Small volumes of local used to treat mild or moderate pain such as
anaesthetic are injected into the cerebrospinal headache (see also MIGRAINE), DYSMENOR-
fluid through a small-bore needle which has RHOEA, and transient musculoskeletal pain.
been inserted through the tissues of the back Some analgesics for example, aspirin and
and the dura mater (the outer membrane sur- paracetamol also reduce PYREXIA. A strong
rounding the spinal cord). A dense motor and non-opioid analgesic is NEFOPAM HYDRO-
sensory blockade is produced in the lower half CHLORIDE, which can be used for persistent
of the body. How high up in the body it reaches pain or pain that fails to respond to other non-
is dependent on the volume and dose of anaes- opioid analgesics, but does have troublesome
thetic, the patients position and individual side-effects. These non-opioid analgesics can be
variation. If the block is too high, then obtained without a doctors prescription over
respiratory-muscle paralysis and therefore the counter (OTC) but the sale of some has to
respiratory arrest may occur. HYPOTENSION be supervised by a qualified pharmacist. A wide
(low blood pressure) may occur because of per- range of compound analgesic preparations is
ipheral vasodilation caused by sympathetic- available, combining, say, aspirin or paraceta-
nerve blockade. Occasionally spinal anaesthesia mol and CODEINE, while the weak stimulant
is complicated by a headache, perhaps caused CAFFEINE is sometimes included in the prepar-
by continuing leakage of cerebrospinal fluid ations. Most of these are OTC drugs. NSAIDs
from the dural puncture point. are especially effective in treating patients with
chronic diseases accompanied by pain and
EPIDURAL ANAESTHESIA Spinal nerves are inflammation. They, too, are sometimes com-
blocked in the epidural space with local anaes- bined with other analgesics.
thetic injected through a fine plastic tube (cath- Paracetamol acts within the central nervous
eter) which is introduced into the space using a system by inhibition of PROSTAGLANDINS. It is
special needle (Tuohy needle). It can be used as often combined with other analgesics for
a continuous technique either by intermittent example, aspirin or codeine; in proprietary
injections, an infusion or by patient-controlled compounds and in therapeutic doses it has
pump. This makes it ideal for surgery in the few side-effects. Overdosage, however, can
lower part of the body, the relief of pain in cause damage to the liver or kidneys (2030
labour and for post-operative analgesia. Com- tablets are sufficient to do this). Paracetamol is
 38 Analysis

often used by individuals attempting suicide. local or systemic attack. An example is the pain,
A Even if there are no immediate symptoms, swelling, eruption, fever and sometimes col-
individuals suspected of having taken an over- lapse that may occur after a wasp sting or inges-
dose should be sent to hospital urgently for tion of peanut in a particularly sensitive person.
treatment. Some people may suffer from anaphylaxis as a
The NSAIDs (including aspirin) inhibit result of allergy to other foods or substances
prostaglandin synthesis. Prostaglandins are such as animal hair or plant leaves. On rare
released by tissues that are inflamed, and may occasions a person may be so sensitive that ana-
cause pain at peripheral pain sensors or sensitise phylaxis may lead to profound SHOCK and col-
nerve endings to painful stimuli: by inhibiting lapse which, unless the affected person receives
their production, pain and inflammation are urgent medical attention, including injection of
reduced. NSAIDs are particularly effective for ADRENALINE, may cause death. (See also
pain produced by inflammation for example, ALLERGY; IMMUNITY.)
ARTHRITIS. Side-effects include gastrointestinal
bleeding (caused by mucosal erosions particu- Anaplasia
larly in the stomach), inhibition of platelet The state in which a body cell loses its distinct-
aggregation (see PLATELETS), and potential for ive characters and takes on a more primitive
renal (kidney) damage. form; it occurs, for example, in cancer, when
Severe pain is often treated with opioid cells proliferate rapidly.
drugs. The original drugs were naturally occur-
ring plant ALKALOIDS (e.g. MORPHINE), whilst Anastomosis
newer drugs are man-made. They mimic the Direct intercommunication of the branches of
action of naturally occurring compounds two or more veins or arteries without any inter-
(ENDORPHINS and ENCEPHALIN) which are vening network of capillary vessels. The term
found within the brain and spinal cord, and act also describes the surgical joining of two hollow
on receptors to reduce the transmission of pain- blood vessels, nerves or organs such as intestines
ful stimuli within the central nervous system to form an intercommunication.
(and possibly peripherally). They tend to pro-
duce side-effects of euphoria, respiratory Anatomy
depression, vomiting, constipation and itching. The science which deals with the structure of
Chronic use or abuse of these drugs may give the bodies of men and animals. Brief descrip-
rise to addiction. tions of the anatomy of each important organ
are given under the headings of the various
Analysis organs. It is studied by dissection of bodies
Analysis means a separation into component bequeathed for the purpose, or of the bodies of
parts by determination of the chemical con- those who die in hospitals and similar institu-
stituents of a substance. The process of analysis tions, unclaimed by relatives.
is carried out by various means, for example:
chromatographic analysis by means of the Ancrod
adsorption column; colorimetric analysis by An ENZYME present in the venom of the
means of various colour tests; densimetric Malayan pit viper, which destroys the
analysis by estimation of the specific gravity; FIBRINOGEN in blood and thereby prevents
gasometric analysis by estimation of the differ- the blood from clotting. In other words it is an
ent gases given off in some process; polariscope anticoagulant (see ANTICOAGULANTS).
analysis by means of the polariscope; and
volumetric analysis by measuring volumes of Ancylostomiasis
liquids. Analysis is also sometimes used as an A parasitic infection caused by the nematodes
abbreviation for PSYCHOANALYSIS. Ancylostoma duodenale and Necator americanus,
resulting in hookworm disease. These infec-
Anaphylactoid Purpura tions are exceedingly common in tropical and
See HENOCH-SCHNLEIN PURPURA. developing countries, millions of people being
affected. Classically, A. duodenale occurred in
Anaphylaxis the Far East, Mediterranean littoral, and Mid-
An immediate (and potentially health- or life- dle East, and N. americanus in tropical Africa,
threatening) hypersensitivity reaction produced Central and South America, and the Far East;
by the bodys immunoglobulin E (IgE) anti- however, in recent years, geographical separ-
bodies to a foreign substance (antigen); the ation of the two human species is less distinct.
affected tissues release histamine which causes In areas where standards of hygiene and sanita-
 Aneurysm 39

tion are unsatisfactory, larvae (embryos) enter tosterone itself requires implantation into the
via intact skin, usually the feet. Ground itch subcutaneous fat using a trocar and cannula for A
occasionally occurs as larvae enter the body. maximum therapeutic benefit. Testosterone
They then undergo a complex life-cycle, propionate is prepared in an oily solution, as it
migrating through the lungs, trachea, and is insoluble in water; it is effective for three days
pharynx. Adult worms are 513 (mean 12) mm and is therefore administered intramuscularly
in length; their normal habitat is the small twice weekly. Testosterone phenyl-propionate is
INTESTINE especially the jejunum where a long-acting microcrystalline preparation
they adhere to the mucosa by hooks, thus caus- which, when given by intramuscular or sub-
ing seepage of blood into the lumen. A worm- cutaneous injection, is effective for four weeks.
pair produces large numbers of eggs, which are Testosterone enantate is another long-acting
excreted in faeces; when deposited on moist soil intramuscular preparation. Mesterolone is an
they remain viable for many weeks or months. effective oral androgen and is less hepatoxic: it
Clinical manifestations include microcytic does not inhibit pituitary gonadotrophic pro-
hypochromic ANAEMIA, hypoalbuminaemia duction and hence spermatogenesis is
(low serum protein) and, in a severe case, unimpaired. Testosterone undecanoate is also
OEDEMA. A chronic infection in childhood can an effective oral form.
give rise to physical, mental and sexual retard-
ation. Treatment is with one of the benzimida- Anencephaly
zole compounds, usually mebendazole or The term given to the condition in which a
albendazole; however, in developing countries, child is born with a defect of the skull and
cheaper preparations are used, including tetra- absence of the brain. Anencephaly is the most
chloroethylene, bephenium hydroxynaph- common major malformation of the central
thoate, and pyrantel embonate. Anaemia usu- nervous system. It has an incidence of 065 per
ally responds to iron supplements; blood trans- 1,000 live births. There is complete absence of
fusion is rarely indicated. the cerebral hemispheres and overlying skull,
and the brain stem and cerebellum are atrophic.
Ancylostoma braziliensis A nematode If the pregnancy goes to term the infants rap-
infection of dogs, which in humans causes local idly die, but in 50 per cent of pregnancies
disease (larva migrans) only, generally on the associated with anencephaly, spontaneous abor-
soles of the feet. It is usually acquired by walk- tion occurs. It is possible to detect the presence
ing on beaches contaminated with dog faeces in of anencephaly in the fetus by measuring the
places such as the Caribbean. level of ALPHA-FETO PROTEIN in the mothers
serum or in the amniotic fluid. (See also SPINA
Androgen BIFIDA.)
The general term for any one of a group of
HORMONES which govern the development of Aneuploidy
the sexual organs and the secondary sexual The state in which there is an abnormal num-
characteristics of the male. TESTOSTERONE, the ber of CHROMOSOMES: for example, DOWNS
androgenic hormone formed in the interstitial (DOWN) SYNDROME and TURNERS SYNDROME.
cells of the testis (see TESTICLE), controls the
development and maintenance of the male sex Aneurine
organs and secondary sex characteristics. In Aneurine is an alternative name for vitamin B1.
small doses it increases the number of sperm- (See THIAMINE.)
atozoa (see SPERMATOZOON) produced, but in
large doses it inhibits the gonadotrophic activ- Aneurysm
ity of the anterior PITUITARY GLAND and sup- A localised swelling or dilatation of an artery
presses the formation of the spermatozoa. It is (see ARTERIES) due to weakening of its wall. The
both androgenic and anabolic in action. The most common sites are the AORTA, the arteries
anabolic effect includes the ability to stimulate of the legs, the carotids and the subclavian
protein synthesis and to diminish the catabol- arteries. The aorta is the largest artery in the
ism of amino acids, and this is associated with body and an aneurysm may develop anywhere
retention of nitrogen, potassium, phosphorus in it. A dissecting aneurysm usually occurs in
and calcium. Doses in excess of 10 mg daily to the first part of the aorta: it is the result of
the female may produce VIRILISM. degeneration in the vessels muscular coat lead-
Unconjugated testosterone is rarely used ing to a tear in the lining; blood then enters the
clinically because its derivatives have a more wall and tracks along (dissects) the muscular
powerful and prolonged effect, and because tes- coat. The aneurysm may rupture or compress
 40 Angina

the blood vessels originating from the aorta: the medical therapy. The surgery is often demand-
A outcome is an INFARCTION in the organs sup- ing and is therefore usually undertaken only
plied by the affected vessel(s). Aneurysms may when the aneurysm is large and the risk of rup-
also form in the arteries at the base of the brain, ture is therefore increased. The patients general
usually due to an inherited defect of the arterial fitness for surgery is also an important con-
wall. sideration. The surgery usually involves either
Aneurysms generally arise in the elderly, with bypassing or replacing the affected part of the
men affected more commonly than women. artery using a conduit made either of vein or of
The most common cause is degenerative a man-made fibre which has been woven or
atheromatous disease, but other rarer causes knitted into a tube. Routine X-ray scanning of
include trauma, inherited conditions such as the abdominal aorta is a valuable preventive
MARFANS SYNDROME, or acquired conditions procedure, enabling cold surgery to be per-
such as SYPHILIS or POLYARTERITIS NODOSA. formed on identified aneurysms.
Once formed, the pressure of the circulating
blood within the aneurysm causes it to increase Angina
in size. At first, there may be no symptoms or A feeling of constriction or suffocation often
signs, but as the aneurysm enlarges it becomes accompanied by pain (see ANGINA PECTORIS).
detectable as a swelling which pulsates with
each heartbeat. It may also cause pain due to Angina Pectoris
pressure on local nerves or bones. Rupture of Pain in the centre of the chest. Usually, exercise
the aneurysm may occur at any time, but is sometimes acute anxiety brings it on and
much more likely when the aneurysm is large. pain may be severe and felt also in the arms
Rupture is usually a surgical emergency, because and the jaw. The condition, which is aggra-
the bleeding is arterial and therefore consider- vated by cold weather, is the result of the
able amounts of blood may be lost very rapidly, hearts demand for blood being greater than
leading to collapse, shock and even death. Rup- that which the coronary arteries can provide.
ture of an aneurysm in the circle of Willis This failure is most often due to narrowing of
causes subarachnoid haemorrhage, a life- the coronary arteries by ATHEROMA; rarely, it
threatening event. Rupture of an aneurysm in may be caused by congenital defects in the
the abdominal aorta is also life-threatening. arteries rendering them incapable of carrying
sufficient blood to meet increased demands
Treatment Treatment is usually surgical. from the body.
Once an aneurysm has formed, the tendency is Angina may be relieved or prevented by such
for it to enlarge progressively regardless of any drugs as glyceryl trinitrate and propranolol. If

Aneurysm in wall of artery (top left). A dissecting aneurysm with the flow of blood splitting the arterial
wall longitudinally (top right). A berry aneurysm in fork of the junction of two arteries (bottom).
 Ankle 41

drug treatment does not work, surgery on the ANGIOTENSIN-CONVERTING ENZYME (ACE)
coronary arteries such as angioplasty or bypass INHIBITORS.) A
grafts may be necessary. People who suffer from
angina pectoris need advice on their lifestyle, Angiotensin-Converting
and in particular on diet, exercise and avoid- Enzyme (ACE) Inhibitors
ance of smoking or excessive alcohol consump- The ENZYME that converts angiotensin I to
tion. They may have high blood pressure, angiotensin II (see ANGIOTENSIN) is called
which will also require medical treatment (see angiotensin-converting enzyme. Angiotensin II
HEART, DISEASES OF; HYPERTENSION). controls the blood pressure and is the most
potent endogenous pressor substance produced
Angiocardiography in the body; angiotensin I has no such pressor
Radiography of the heart after injection into it activity. Inhibition of the enzyme that converts
of a radio-opaque substance. angiotensin I to angiotensin II will thus have
marked effects on lowering the blood pressure,
Angiography and ACE inhibitors have a valuable role in treat-
Radiography of blood vessels made visible by ing heart failure when thiazides and beta
injecting into them a radio-opaque substance. blockers cannot be used or fail to work, espe-
In the case of arteries this is known as arteriog- cially after myocardial infarction (see HEART,
raphy; the corresponding term for veins being DISEASES OF). Captopril was the first ACE
venography or phlebography. This procedure inhibitor to be synthesised: it reduces peripheral
demonstrates whether there is any narrowing or resistance by causing arteriolar dilatation and
ballooning of the lumen of the vessel, changes thus lowers blood pressure. Other drugs such as
usually caused by disease or injury. enalapril, lisinopril, cilazapril, quinapril and
ramipril have since been developed. Some
Angioma kidney disorders increase the production of
A TUMOUR composed of blood vessels. (See angiotensin II and so cause HYPERTENSION.
NAEVUS.)
Angitis
Angio-Oedema Angitis (or angiitis) means inflammation of a
Also called angioneurotic oedema; see under vessel such as a blood vessel, lymph vessel, or
URTICARIA. bile duct.

Angioplasty ngstrm Unit

A method of treating blockage or narrowing of Called after the Swedish physicist, this is a
a blood vessel by recanalising the vessel that is, measurement of length and equals 1/10,000 of
inserting a balloon into the constriction to a micrometre, or one-hundred-millionth of a
reopen it. The technique is used to treat a nar- centimetre. It is represented by the symbol
rowed artery in the heart or a limb. About 65 and is used to give the length of electromagnetic
per cent of patients treated benefit, but when waves.
symptoms persist or recur the procedure may be
repeated. There is a small risk of damage to the Anhidrosis
vessel or valve. New procedures under devel- Anhidrosis is an abnormal diminution in the
opment include the use of lasers, cutting drills secretion of sweat. This may be caused by
and suction to remove the deposits of disease or by a congenital defect.
ATHEROMA blocking the arteries.
Animal Starch
Angiotensin See GLYCOGEN.
Angiotensin is a peptide that occurs in two
forms: I and II. The former results from the Anisocytosis
action of the ENZYME, RENIN on alpha globulin This means inequality in the size of erythro-
(a protein) produced by the liver and passed cytes (red blood cells); it occurs in many forms
into the blood. During passage of the blood but is prominent in megaloblastic ANAEMIA.
through the lungs, angiotensin I is converted
into an active form, angiotensin II, by an Ankle
enzyme. This active form constricts the blood The joint between the leg bones (TIBIA and FIB-
vessels and stimulates the release of two hor- ULA) above, and the TALUS (the Roman dice-
mones VASOPRESSIN and ALDOSTERONE bone) below. It is a very strong joint with
which raise the blood pressure. (See also powerful ligaments binding the bones together
 42 Ankylosing Spondylitis

at either side, and bony projections from the leg

A bones, which form large bosses on either side, Anoxia
That state in which the body tissues have an
called the outer and inner malleoli, extending inadequate supply of OXYGEN. This may be
about 12 mm (half an inch) below the actual because the blood in the lungs does not receive
joint. Two common injuries near the ankle are a enough oxygen, or because there is not enough
sprain, on the inner side, consisting of tearing blood to receive the oxygen, or because the
of the internal ligament; and fracture of the fib- blood stagnates in the body.
ula (Potts fracture) on the outer side. (See also
JOINTS, DISEASES OF.) Antabuse
See DISULFIRAM.
Ankylosing Spondylitis
See SPINE AND SPINAL CORD, DISEASES AND
Antacids
INJURIES OF.
Drugs traditionally used to treat gastrointestinal
Ankylosis disorders, including peptic ulcer. They neutral-
The condition of a joint in which the move- ise the hydrochloric acid secreted in the stom-
ments are restricted by fibrous bands, or by mal- achs digestive juices and relieve pain and the
formation, or by actual union of the bones. (See discomfort of DYSPEPSIA (indigestion). A large
JOINTS, DISEASES OF.)
number of proprietary preparations are on sale
to the public and most contain compounds of
Ankylostoma aluminium or magnesium or a mixture of the
See ANCYLOSTOMIASIS. two. Other agents include activated dime-
thicone an antifoaming agent aimed at reliev-
Anodynes ing flatulence; alginates, which protect against
Any drug or treatment that eases pain. These reflux oesophagitis; and surface anaesthetics.
may range from opium the oldest and most Antacids commonly prescribed by doctors
powerful anodyne but a highly addictive sub- include aluminium hydroxide, magnesium car-
stance through ANALGESICS, to warmth and bonate and magnesium trisilicate. Sodium
massage. bicarbonate and calcium and bismuth com-
pounds are also used, although the latter is best
Anopheles avoided as it may cause neurological side-
The generic name of a widely distributed group
effects. (See DUODENAL ULCER; STOMACH, DIS-
of mosquitoes, certain species of which transmit
EASES OF.)
to humans the parasitic protozoa Plasmodium,
the agent that causes MALARIA. Anopheles macu- Antagonist
lipennis and A. bifurcatus are both found in (1) A muscle the contraction of which opposes
England and can both transmit the malaria that of another muscle called the AGONIST.
parasite. When the agonist contracts, the antagonist
Anorexia relaxes.
Loss of APPETITE. (2) The action of one drug in opposing the
action of another.
Anorexia Nervosa
See under EATING DISORDERS. Ante-
Prefix meaning before or forwards.
Anorgasmia
An individuals inability to achieve ORGASM. Anteflexion
The abnormal forward curvature of an organ in
Anosmia which the upper part is sharply bent forwards.
Loss of sense of smell. (See NOSE, DISORDERS
The term is especially applied to forward
OF.)
displacement of the UTERUS.
Anovular
Absence of OVULATION. Anovular menstru- Antenatal Care
ation occurs when a woman takes the contra- The protocol which doctors and midwives fol-
ceptive pill (see under CONTRACEPTION Non- low to ensure that the pregnant mother and her
barrier methods). FETUS are kept in good health, and that the
pregnancy and birth have a satisfactory out-
Anoxaemia come. The pregnant mother is seen regularly at
Reduction of the oxygen content of the blood a clinic where, for example, her blood pressure
below normal limits. is checked, the growth and development of her
 Anthrax 43

child-to-be are carefully assessed, and any prob- Kingdom. The cause is a bacillus (B. anthracis)
lem or potential problems dealt with. Most which grows in long chains and produces A
antenatal care deals with normal pregnancies spores of great vitality. These spores retain their
and is supervised by general practitioners and life for years, in dried skins and fleeces; they are
midwives in primary-care clinics. If any serious not destroyed by boiling, freezing, 5 per cent
problems are identified, the mother can be carbolic lotion, or, like many bacilli, by the gas-
referred to specialists clinics in hospitals. (See tric juice. The disease is communicated from a
PREGNANCY AND LABOUR.) diseased animal to a crack in the skin (e.g. of a
farmer or butcher), or from contact with con-
Antepartum taminated skins or fleeces. Nowadays skins are
An adjective describing an event before labour handled wet, but if they are allowed to dry so
starts in pregnancy (see PREGNANCY AND that dust laden with spores is inhaled by the
LABOUR). workers, serious pneumonia may result.
Instances have occurred of the disease being
Anterior conveyed on shaving brushes made from bris-
An adjective that describes or relates to the tles of diseased animals. A few countries are
front part of the body, limbs, or organs. believed to have developed anthrax as a weapon
of war to be delivered by shells or rockets, des-
Anterior Tibial Syndrome pite international agreements to ban such
See under MUSCLES, DISORDERS OF Compres- weapons.
sion syndrome. In the wake of the devastating terrorist
attacks on buildings in New York and Washing-
ton on 11 September 2001, modified anthrax
Anteversion spores were sent by mail from an unidentified
The term applied to the forward tilting of an
source to some prominent Americans. Several
organ, especially of the UTERUS.
people were infected and a few died. This was
the first known use of anthrax as a terror
Anthelmintics weapon.
Substances which cause the death or expulsion Prevention is most important by disinfecting
of parasitic worms such as hook, tape and all hides, wool and hair coming from areas of
threadworms (see TAENIA; ENTEROBIASIS). the world. An efficient vaccine is now available.
Treatment consists of the administration of
Anthracosis large doses of the broad-spectrum antibiotic,
The change which takes place in the lungs and CIPROFLOXACIN. If bioterrorism is thought to
bronchial glands of coal-miners, and others, be the likely source of anthrax infection,
who inhale coal-dust constantly. The lungs are appropriate decontamination procedures must
amazingly efficient in coping with this prob- be organised promptly.
lem; during a working lifetime a coal-miner
may inhale around 5,000 grams of dust, but at Symptoms
POST-MORTEM EXAMINATION it is rare to find
more than about 40 grams in the lungs. The EXTERNAL FORM This is the malignant pus-
affected tissues change in colour from greyish tule. After inoculation of some small wound, a
pink to jet black, owing to loading with minute few hours or days elapse, and then a red,
carbon particles. (See PNEUMOCONIOSIS.) inflamed swelling appears, which grows larger
till it covers half the face or the breadth of the
Anthracyclines arm, as the case may be. Upon its summit
ANTIBIOTICS that destroy tumour cells: appears a bleb of pus, which bursts and leaves a
examples include aclarubicin, daunorubicin, black scab, perhaps 12 mm (half an inch) wide.
doxorubicin, epirubicin and idarubicin. The patient is feverish and seriously ill. The
inflammation may last ten days or so, when it
Anthrax slowly subsides and the patient recovers, if sur-
A serious disease occurring in sheep and cattle, viving the fever and prostration.
and in those who tend them or handle the
bones, skins and fleeces even long after INTERNAL FORM This takes the form of pneu-
removal of the latter from the animals. It is monia with haemorrhages, when the spores
sometimes referred to as malignant pustule, have been drawn into the lungs, or of ulcers of
wool-sorters disease, splenic fever of animals, or the stomach and intestines, with gangrene
murrain. It is now a rare condition in the United of the SPLEEN, when they have been swallowed.
 44 Anti-

It is usually fatal in two or three days. Victims The cephalosporin nucleus 7 amino cepha-
A may also develop GASTROENTERITIS or losporanic (7-ICA) acid has been the basis for
MENINGITIS. the production of the semi-synthetic com-
pounds of the cephalosporin nucleus. The first
Anti- semi-synthetic cephalosporin, cephalothin,
Prefix meaning against. appeared in 1962; it was followed by cephalori-
dine in 1964. The original cephalosporins had
Antiarrhythmic Drugs to be given by injection, but more recent pre-
ARRHYTHMIA is a variation in the normal parations can be given by mouth. The newer
rhythm of the heartbeat. Management of the preparations are less readily destroyed by beta-
condition requires accurate diagnosis of the lactamases and so they have a much broader
type, and ELECTROCARDIOGRAPHY is vital in spectrum of antibacterial activity. The newer
this process (see HEART, DISEASES OF). Drug cephalosporins include cephalexin, cefazolin,
treatment is usually part of the management, cephacetrile, cephapirin, cefamandole, cefurox-
and antiarrhythmic drugs can be divided clinic- ine, cephrodine, cefodroxil and cefotaxine.
ally into those that act on supraventricular Inactivation of beta-lactamase is the basis of
arrhythmias, those that act on both supraven- bacterial resistance both to the penicillins and
tricular and ventricular arrythmias, and those to the cephalosporins, so that attempts to pre-
that act on ventricular arrythmias. Respective pare these antibiotics with resistance to beta-
examples are VERAPAMIL, DISOPYRAMIDE and lactamase is of great importance. A synthetic
LIDOCAINE. This large group of drugs can also inhibitor of beta-lactamase called clavulanic
be classified according to their effects on the acid has been synthesised; this is used in
electrical reactions of active myocardial cells. combination with the penicillins and cepha-
The many drugs available are described in the losporins to prevent resistance. The cephamy-
British National Formulary. cins are a new addition to the beta-lactam
antibiotics. They are similar in structure to the
Antibacterial Drugs cephalosporins but are produced, not by fungi,
A group of drugs, which include ANTIBIOTICS, but by actinomycetes.
used to treat infections caused by BACTERIA. Overuse and misuse of antibiotics have
Drugs include CEPHALOSPORINS and cephamy- resulted in many bacteria becoming resistant to
cins, TETRACYCLINES, AMINOGLYCOSIDES, them. Hospitals, in particular, have problems
MACROLIDES, and antituberculous compounds. with METHICILLIN-RESISTANT STAPHYLOCOC-
CUS AUREUS (MRSA). Combinations of anti-
Antibiotics biotics are needed to combat resistant strains of
Antibiotic is the term used to describe any anti- bacteria, another example being Mycobacterium
bacterial agent derived from micro-organisms, tuberculosis.
although most of them are now prepared syn-
thetically. Such agents destroy or inhibit the Antibodies
growth of other micro-organisms: examples are Antibodies are substances in the blood which
penicillin, cephalosporin, amino-glycosides, destroy or neutralise various toxins or bodies
streptomycin, and tetracycline. (e.g. bacteria), known generally as antigens (see
Penicillin was the first antibiotic to be dis- ANTIGEN). The antibodies are formed, usually,
covered and used in the 1940s. The discovery as a result of the introduction into the body of
and isolation in 1958 of the penicillin nucleus, the antigens to which they are antagonistic, as
6-amino penicillanic acid (6-PNA), allowed in all infectious diseases (see ALLERGY;
many new penicillins to be synthesised. These IMMUNITY).
are now the largest single group of antibiotics
used in clinical medicine. Most staphylococci Anticholinergic
(see STAPHYLOCOCCUS) have now developed An action or drug that inhibits the activity of
resistance to benzylpenicillin, the early form of ACETYLCHOLINE.
the drug, because they produce penicillinases
enzymes which break down the drug. Other Anticholinesterase
types of penicillin such as cloxacillin and flu- Any compound that inhibits the activity of
coxacillin are not affected and are used against CHOLINESTERASE, thus permitting ACETYL-
penicillin-resistant staphylococci. CHOLINE to continue its function of transmit-
The cephalosporins are derived from the ting nerve impulses. Drugs with anticholineste-
compound cephalosporin C, which is obtained rase properties include distigmine, NEOSTIG-
by fermentation of the mould cephalosporium. MINE and PHYSOSTIGMINE.
 Antidepressant Drugs 45

Anticoagulants Antidepressant Drugs A

Anticoagulants are drugs which inhibit COAGU- These widely used drugs include a range of dif-
LATION of the blood. They are used to prevent ferent preparations which relieve DEPRESSION.
and treat abnormal clotting of the blood, to All the antidepressants available at the time of
treat THROMBOSIS, and sometimes to prevent writing are more or less equally effective. In
or treat STROKE or TRANSIENT ISCHAEMIC studies where patients agree to take either anti-
ATTACKS OR EPISODES (TIA, TIE). Anticoagulant depressants or identical dummy PLACEBO pills
drugs are also prescribed preventively in major (without knowing which), at least two-thirds of
surgery to stop abnormal clotting from occur- those who receive antidepressants feel much
ring; HAEMODIALYSIS is another procedure dur- better within three months, while fewer than
ing which these drugs are used. Anticoagulants one-third of those on placebos recover naturally
are also prescribed to prevent thrombi (clots) in the same period. In general these drugs are
forming on prosthetic heart valves after heart useful for severe and moderate depression
surgery. including postnatal illness; they are not effective
The drugs are much more effective in the in milder forms of depression although they
treatment and prevention of venous clotting may be tried for a short time if other therapies
for example, deep vein thrombosis (DVT), see have failed.
under VEINS, DISEASES OF than in preventing The most widely prescribed type of anti-
thrombosis formation in arteries with their fast- depressants are the tricyclics, so-called because
flowing blood in which thrombi contain little their molecular structure includes three rings.
fibrin (against which the anticoagulants work) The other commonly used types are named
and many PLATELETS. after the actions they have on chemicals in the
The main anticoagulants now in use are the brain: the SELECTIVE SEROTONIN-REUPTAKE
natural agent HEPARIN (a quick-acting variety INHIBITORS (SSRIS) and the MONOAMINE OXI-
and a low-molecular-weight long-acting type); DASE INHIBITORS (MAOIS) see also below. All
synthetic oral anticoagulants such as WARFARIN types of antidepressant work in similar ways.
and the less-often-used acenocoumarol and Tricyclic antidepressants have cured depression
PHENINDIONE; and antiplatelet compounds in millions of people, but they can cause
such as ASPIRIN, clopidogrel dipyridamole and unpleasant side-effects, particularly in the first
ticlopidines. Fondaparinux is an extract of hep- couple of weeks. These include SEDATION, dry
arin which can be given once daily by injection; mouth, excessive sweating, CONSTIPATION,
ximelagatran, an inhibitor of thrombin, is being urinary problems, and impotence (inability to
trialled as the first new oral anticoagulant since get an erection). Up to half of all people pre-
heparin. scribed tricyclic drugs cannot tolerate the side-
Patients taking anticoagulants need careful effects and stop treatment before their depres-
medical monitoring and they should carry an sion is properly treated. More seriously, tri-
Anticoagulant Card with instructions about the cyclics can upset the rhythm of the heart in
use of whatever drug they may be receiving susceptible people and should never be given in
essential information should the individual the presence of heart disease.
require treatment for other medical conditions The SSRIs are newer, coming into wide use
as well as for thrombosis. in the late 1980s. They increase the levels in the
brain of the chemical messenger SEROTONIN,
Anticonvulsants which is thought to be depleted in depression.
Drugs that reduce or prevent the severity of an Indeed, the SSRIs are as effective as tricyclics
epileptic convulsion or seizure (see EPILEPSY). and, although they can cause nausea and exces-
The nature of the fit, and the patients reaction sive sweating at first, they generally have fewer
to it, influences the type of anticonvulsant side-effects. Their main disadvantage, however,
used. Anticonvulsants inhibit the high level of is that they cost much more than the most
electrical activity in the brain that causes the commonly used tricyclic, amitriptyline. On the
fit. Among regularly used anticonvulsants are other hand, they are more acceptable to many
carbamazepine, sodium valproate, clonaz- patients and they cause fewer drop-outs from
opam, lamotrigine, gabapentin, vigabatrin, treatment up to a quarter rather than a half.
and topiramate. Older drugs such as pheny- The money saved by completed, successful
toin and primidone remain useful in some treatment may outweigh the prescribing costs.
patients. Intravenous anticonvulsants, such as SSRIs have been reported as associated with an
diazepam, are used for rapid control of epi- increased risk of suicide.
leptic status. Another group of antidepressants, the
MAOIs, have been in use since the late 1950s.
 46 Antidiarrhoeal Treatments

They are stimulants, rather than sedatives, and groups include flupenthixol, mertazapine and
A are particularly helpful for people who are phys- venlafaxine.)
ically and mentally slowed by depression. They
work well but have one big disadvantage a Antidiarrhoeal Treatments
dangerous interaction with certain foods and Initial treatment of acute DIARRHOEA is to pre-
other drugs, causing a sudden and very danger- vent or correct the loss of fluid and ELECTRO-
ous increase in blood pressure. People taking LYTES from the body. This is a priority espe-
them must carry an information card explain- cially in infants and elderly people. Rehydration
ing the risk and listing the things that they can be achieved orally or, in severe cases, by
should avoid. Because of this risk, MAOIs are urgent admission to hospital for the replace-
not used much now, except when other treat- ment of fluid and electrolytes.
ments have failed. A new MAOI, For adults with acute diarrhoea, short-term
moclobemide, which is less likely to interact symptomatic treatment can be achieved with
and so cause high blood pressure, is now antimotility drugs such as codeine phosphate,
available. co-phenotrope or loperamide hydrochloride.
LITHIUM CARBONATE is a powerful anti- Adsorbent drugs, for example, KAOLIN, should
depressant used for intractable depression. It not be used in acute diarrhoea, but bulk-
should be used under specialist supervision as forming drugs ispaghula or methylcellulose
the gap between an effective dose and a toxic can help to control the consistency of faeces
one is narrow. in patients with ileostomies and colostomies
St Johns Wort is a popular herbal remedy (see ILEOSTOMY; COLOSTOMY), or those with
which may be effective, but which is diarrhoea caused by DIVERTICULAR DISEASE.
handicapped by differences of strength Irritable bowel syndrome, malabsorption
between different preparations or batches. It syndrom, ulcerative colitis, Crohns disease and
can interact with a number of conventional diverticular disease are often accompanied by
drugs and so needs to be used cautiously and diarrhoea; for more information on these con-
with advice. ditions, see under separate entries.
In general, antidepressants work by restoring ANTIBIOTICS may sometimes cause diarrhoea
the balance of chemicals in the brain. Improved and this side-effect should be borne in mind
sleep and reduced anxiety are usually the first when the cause of the condition is being
signs of improvement, particularly among investigated.
people taking the more sedative tricyclic drugs.
Improvement in other symptoms follow, with Antidiuretic Hormone (ADH)
the mood starting to lift after about two weeks See VASOPRESSIN.
of treatment. Most people feel well by three
months, although a few residual symptoms,
such as slowness in the mornings, may take Antidotes
longer to clear up. People taking antidepres- An antidote is a therapeutic substance used to
sants usually want to stop them as soon as they counteract the toxic action(s) of a specific sub-
feel better; however, the risk of relapse is high stance. Very few substances have an antidote.
for up to a year and most doctors recommend
continuing the drugs for around 46 months Antiemetic
after recovery, with gradual reduction of the A drug that counteracts nausea and sickness.
dose after that. Some antihistamines and anticholinergics have
Withdrawal reactions may occur including an antiemetic effect. They are used to combat
nausea, vomiting, headache, giddiness, panic or motion sickness or nausea and vomiting
anxiety and restlessness. The drugs should be brought on by other drugs in particular, drugs
withdrawn gradually over about a month or used in ANAESTHESIA and anticancer agents
longer (up to six months in those who have and by RADIOTHERAPY.
been on maintenance treatment).
A wide range of antidepressant drugs is Antigen
described in the British National Formulary. Whenever the body identifies a substance enter-
Examples include: ing it as foreign or potentially dangerous, the
Tricyclics:
doxepin.
amitryptyline, imipramine, immune system (see IMMUNITY) produces an an
antibody (see ANTIBODIES) to combat it. Anti-
MAOIs: phenelzine, isocarboxazid. gens are normally proteins, but simple sub-
SSRIs: citalopram, fluoxetine, paraxtene.
(Antidepressant drugs not in these three
stances for instance, metals may become
antigenic by combining with and changing the
 Antiperistalsis 47

bodys own proteins. Such a product is called a coronary thrombosis (see HEART, DISEASES OF).
hapten. Drugs used for treatment can be classified as A
follows: diuretics; vasodilator antihypertensives;
Antihelminthic centrally acting antihypertensives; adrenergic
See ANTHELMINTICS. neurone-blocking drugs; alpha-adrenoreceptor-
blocking drugs; drugs affecting the renin-
Antihistamine Drugs angiotensin system; ganglion-blocking drugs;
Antihistamine drugs antagonise the action of and tyrosine hydroxylase inhibitors. The drugs
HISTAMINE and are therefore of value in the prescribed depend on many factors, including
treatment of certain allergic conditions (see the type of hypertension being treated. Treat-
ALLERGY). They may be divided into those ment can be difficult because of the need to
with a central action (e.g. flupheniramine and balance the effectiveness of a drug in reducing
cyclizine) and those such as loratidine and ter- blood pressure against its side-effects.
fenadine with almost no central action. Anti-
histamines are also of some value in the treat- Anti-Inflammatory Drugs
ment of vasomotor RHINITIS (see also under See ANALGESICS; NON-STEROIDAL ANTI-
NOSE, DISORDERS OF); they reduce rhinorrhoea INFLAMMATORY DRUGS (NSAIDS).
and sneezing but are usually less effective in
relieving nasal congestion. All antihistamines Antimetabolites
are useful in the treatment of URTICARIA and A group of drugs used in the treatment of cer-
certain allergic skin rashes, insect bites and tain forms of malignant disease. Chemically,
stings, as well as in the treatment of drug aller- they closely resemble substances (or METABOL-
gies. Chlorpheniramine or promethazine injec- ITES) which are essential for the life and growth
tions are useful in the emergency treatment of CELLS. Antimetabolites are incorporated into
of angio-oedema (see under URTICARIA) and new nuclear material in the cell or combine
ANAPHYLAXIS. irreversibly with essential cellular enzymes, thus
There is little evidence that any one anti- disrupting normal cellular division (see MITOSIS
histamine is superior to another, and patients and MEIOSIS) and causing death of the cell.
vary considerably in their response to them. There is now a range of antimetabolites includ-
The antihistamines differ in their duration of ing CYTARABINE, METHOTREXATE, FLUOROUR-
action and in the incidence of side-effects such ACIL and MERCAPTOPURINE.
as drowsiness. Most are short-acting, but some
(such as promethazine) work for up to 12 Antimuscarine
hours. They all cause sedation but promethaz- A pharmacological effect where the action of
ine, trimeprazine and dimenhydrinate tend to ACETYLCHOLINE, a chemical neurotransmitter
be more sedating while chlorpheniramine and released at the junctions (synapses) of para-
cyclizine are less so, as are astemizole, oxato- sympathetic and ganglionic nerves, is inhibited.
mide and terfenadine. Patients should be The junctions between nerves and skeletal
warned that their ability to drive or operate muscles have nicotinic receptors. A wide range
machinery may be impaired when taking these of drugs with antimuscarinic effects are in use
drugs, and that the effects of ALCOHOL may be for various disorders including PSYCHOSIS,
increased. BRONCHOSPASM, disorders of the eye (see EYE,
DISORDERS OF), PARKINSONISM, and problems
Antihypertensive Drugs of the GASTROINTESTINAL TRACT and URINARY
A group of drugs used to treat high blood pres- TRACT. (See also ANTISPASMODICS.)
sure (HYPERTENSION). Untreated hypertension
leads to STROKE, heart attacks and heart failure. Antioxidant
The high incidence of hypertension in western A compound that can neutralise oxygen-free
countries has led to intensive research to dis- radicals in the body; these are atoms and chem-
cover antihypertensive drugs, and many have ical groups that can damage cells. Free radicals
been marketed. The drugs may work by are the product of various disease processes as
reducing the power of the heartbeat, by dilating well as of such agents as poisons, radiation and
the blood vessels or by increasing the excretion smoking. Natural antioxidants also occur in the
of salts and water in the urine (diuresis). Anti- body.
hypertensive treatment has greatly improved
the prognosis of patients with high blood pres- Antiperistalsis
sure by cutting the frequency of heart and renal A movement in the bowels and stomach by
failure (see KIDNEYS, DISEASES OF), stroke, and which the food and other contents are passed
 48 Antipsychotic Drugs

A
upwards, instead of in the proper direction. (See Antivenom
PERISTALSIS.) A therapeutic substance used to counteract the
toxic action(s) of a specific animal toxin (see
Antipsychotic Drugs TOXINS) or venom. They are normally steril-
See NEUROLEPTICS. ised, proteinaceous globulins (see GLOBULIN)
extracted from the SERUM of animals, usually
Antipyretics horses, immunised against the specific toxin/
Measures used to reduce temperature in FEVER. venom. Most are given by intravenous or
Varieties include cold-sponging, wet-packs, intramuscular injection and are most effective
baths and diaphoretic (sweat-reducing) drugs when given shortly after the bite or sting has
such as QUININE, salicylates and ASPIRIN. occurred. Some antivenoms may be effective
against the venoms of several closely related
Antiseptics animal species.
Antiseptics prevent the growth of disease-
causing micro-organisms without damaging liv- Antrostomy
ing tissues. Among chemicals used are boric Antrostomy is the operation in which an open-
acid, carbolic acid, hydrogen peroxide and ing is made through the nose into the maxillary
products based on coal tar, such as cresol. Chlor- ANTRUM.
hexidines, iodine, formaldehyde, flavines,
alcohol and hexachlorophane are also used. Antrum
Antiseptics are applied to prevent infection Antrum means a natural hollow or cavity. The
for example, in preparing the skin before oper- maxillary antrum is now known as the maxil-
ation. They are also used externally to treat lary SINUS. The mastoid antrum is situated in
infected wounds. the mastoid process, the mass of bone felt
behind the ear. It may become the seat of an
Antispasmodics ABSCESS in cases of suppuration of the middle
These are antimuscarinic drugs (see ANTIMUS- ear (see EAR, DISEASES OF). The pyloric antrum
CARINE) which have the property of relaxing is the part of the stomach immediately preced-
smooth muscle. Along with other antimus- ing the PYLORUS.
carinic drugs, antispasmodics may be helpful
supportive treatment for patients with non- Anuria
ulcer DYSPEPSIA, IRRITABLE BOWEL SYNDROME Anuria is a condition in which no URINE is
(IBS) and DIVERTICULAR DISEASE. Examples of voided. (See also KIDNEYS, DISEASES OF
antispasmodic drugs are ATROPINE sulphate, Glomerulonephritis.)
dicyclomine bromide and propantheline (a syn-
thetic antimuscarinic drug used as a treatment Anus
adjunct in gastrointestinal disorders and also for The anus is the opening at the lower end of the
controlling urinary frequency), bromide, alver- bowel. It is kept closed by two muscles, the
ine, mebervine and peppermint oil. With the external and internal sphincters. The latter is a
arrival of more powerful and specific antisecre- muscular ring which extends about 25 mm (1
tory drugs, such as the histamine H2-receptor inch) up the bowel, is nearly 6 mm ( inch)
antagonists examples are CIMETIDINE and thick, and is kept constantly contracted by the
RANITIDINE the use of antispasmodics has action of a nerve centre in the spinal cord. In
declined. disease of the spinal cord the muscle may be
paralysed, resulting in inability to retain the
Antitoxin motions or stools.
Any one of various preparations that contain
ANTIBODIES which combine and neutralise the Anus, Diseases of
effects of a particular toxin (see TOXINS) See under RECTUM, DISEASES OF.
released into the bloodstream by BACTERIA.
Examples are the toxins produced by DIPH- Anxiety State
THERIA and TETANUS. Antitoxins are produced See NEUROSIS.
from the blood of humans or animals that
have been exposed to a particular toxin Anxiolytics
whether by INFECTION or by INOCULATION Drugs for the relief of anxiety. They will induce
and thus have produced antibodies against it. sleep when given in large doses at night, and so
They are usually given by intramuscular are HYPNOTICS as well. Conversely, most hyp-
injection. notics will sedate when given in divided doses
 Apex 49

during the day. Prescription of these drugs is and ANEURYSM. (See ARTERIES, DISEASES OF;
widespread but physical and psychological COARCTATION OF THE AORTA.) A
DEPENDENCE occurs as well as TOLERANCE to
their effects, especially among those with per- Aortic Incompetence
sonality disorders or who abuse drugs and alco- See also REGURGITATION. This is the back flow of
hol. This is particularly true of the BARBITUR- blood through the AORTIC VALVE of the HEART
ATES which are now limited in their use, but into the left ventricle, caused by an incompe-
also applies to the BENZODIAZEPINES, the most tent valve. The failure to close may be caused by
commonly used anxiolytics and hypnotics. a congenital defect or by damage from disease.
Withdrawal syndromes may occur if drug The defect may be cured by surgical replace-
treatment is stopped too abruptly; hypnotic ment of the damaged valve with an artificial
sedatives and anxiolytics should therefore not valve. (See HEART, DISEASES OF.)
be prescribed indiscriminately, but reserved for
short courses. Among the anxiolytics are the Aortic Stenosis
widely used benzodiazepines, the rarely used Narrowing of the AORTIC VALVE in the HEART
barbiturates, and the occasionally prescribed which obstructs the flow of blood through it,
drugs such as BUSPIRONE and beta blockers like with serious effects on the heart and the circula-
OXPRENOLOL (see BETA-ADRENOCEPTOR- tion. The muscle in the left ventricle works
BLOCKING DRUGS). harder to compensate for the obstruction and
thickens as a result. Stenosis is usually caused by
Aorta the deposition of calcium on the valve and is
The large vessel which opens out of the left commonly associated with ATHEROMA.
ventricle of the HEART and carries blood to all Untreated, the condition leads to heart failure,
of the body. It is about 45 cm (1 feet) long but nowadays the stenosis can be treated
and 25 cm (1 inch) wide. Like other arteries it surgically.
possesses three coats, of which the middle one is
much the thickest. This consists partly of Aortic Valve
muscle fibre, but is mainly composed of an elas- The valve that controls the flow of blood
tic substance called elastin. The aorta passes from the AORTA to the left ventricle of the
first to the right, and lies nearest the surface HEART.
behind the end of the second right rib-cartilage;
then it curves backwards and to the left, passes Aortitis
down behind the left lung close to the back- A rare degenerative condition of the lining of
bone, and through an opening in the dia- the AORTA. It may be the result of arteritis
phragm into the abdomen. There it divides, at (inflammation of the arteries) or a consequence
the level of the navel, into the two common of untreated SYPHILIS. Aortitis may lead to
iliac arteries, which carry blood to the lower thinning of the aortas wall and development of
limbs. an ANEURYSM.
Its branches, in order, are: two coronary
arteries to the heart wall; the brachiocephalic, Aortography
left common carotid, and left subclavian arter- Aortography is the technique of rendering the
ies to the head, neck and upper limbs; several AORTA visible in an X-ray film by injecting a
small branches to the oesophagus, bronchi, and radio-opaque substance into it. The procedure
other organs of the chest; nine pairs of inter- is used to detect the presence of an ANEURYSM.
costal arteries which run around the body (See also ANGIOGRAPHY.)
between the ribs; one pair of subcostal arteries
which is in series with the intercostal arteries; Aperients
four (or five) lumbar arteries to the muscles of Medicines which produce a natural movement
the loins; coeliac trunk to the stomach, liver of the bowels. (See CONSTIPATION;
and pancreas; two mesenteric arteries to the PURGATIVES.)
bowels; and suprarenal, renal and testicular
arteries to the suprarenal body, kidney, and tes- Apex
ticle on each side. From the termination of the The pointed portion of any organ which has a
aorta rises a small branch, the median sacral conical shape. The apex of each lung reaches
artery, which runs down into the pelvis. In the about 355 cm (1 or 2 inches) above the
female the ovarian arteries replace the collar-bone into the neck. In health, the apex of
testicular. the heart can be felt below the fifth rib immedi-
The chief diseases of the aorta are ATHEROMA ately inside the nipple.
 50 Apex Beat

A Apex Beat
This is the beat of the of the HEART,
APEX
Aplasia
The complete or partial failure of tissue or an
which can be felt through the skin to the left organ to develop.
of the breastbone between the fifth and sixth
ribs. Apnoea
A general term meaning the cessation of breath-
Apgar Score ing. Apnoea is a medical emergency: death soon
A method of assessing at birth whether or not a follows if breathing is not quickly restored (see
baby requires resuscitation. The newborn is APPENDIX 1: BASIC FIRST AID). Apnoea may be
routinely assessed at 1 minute of age and again caused by an obstruction to the airway, for
at 5 minutes, and a value of 0, 1 or 2 given to example by the tongue during general ANAES-
each of five signs: colour, heart rate, muscle THESIA, or by a disturbance of the mechanisms
tone, respiratory (or breathing) effort, and the that control breathing. Rapid heavy breathing
response to stimulation. A total score of 7 or reduces the blood levels of carbon dioxide and
more indicates that the newborn child is in can lead to a brief period of apnoea.
excellent condition. An Apgar score of 5 or less Neonatal apnoeic attacks may represent a ser-
at 15 or 20 minutes predicates an increased risk ious emergency, being caused by prematurity,
of subsequent CEREBRAL PALSY. milk aspiration, heart failure, infection, HYP-
OXIA, HYPOGLYCAEMIA or HYPOCALCAEMIA. If
Aphakia stimulation of the baby does not immediately
Absence of the lens of the EYE. restore breathing, then bag-and-mask ventila-
tion should be used.
Aphasia
Inability to speak caused by disease in or injury Apo-
to the cerebral cortex in the left half of the Apo- is a prefix implying separation or deriv-
BRAIN (in a right-handed person), affecting the ation from.
generation and content of speech as well as the
understanding of language; often accompanied Apodia
by problems with reading and writing (see DYS- Absence of the foot.
PHASIA). Comprehension and expression of
language occur in two zones of the cerebral cor- Aponeurosis
tex (the outer layer of the main part of the Aponeurosis is the term applied to the white
brain). They are known as Wernickes area fibrous membrane which serves as an invest-
(comprehension) and Brocas area (speech ment for the muscles and which covers the skull
formulation). beneath the scalp.

Aphonia Apoplexy
Loss of voice, usually sudden. Commonly See STROKE.
caused by emotional stress with no detectable
physical abnormality in the LARYNX. Damage or Apoptosis
disease of the larynx usually results in dyspho- This is a genetically controlled type of cell
nia (partial voice loss). Where no physical cause death. There is an orchestrated collapse of a cell
can be identified, reassurance and, if the voice (see CELLS), typified by destruction of the cells
does not quickly return, PSYCHOTHERAPY are membrane; shrinkage of the cell with condensa-
the treatment. tion of CHROMATIN; and fragmentation of DNA.
The dead cell is then engulfed by adjacent cells.
Aphthous Ulcer This process occurs without evidence of the
Single or multiple (and often recurrent) transi- inflammation normally associated with a cells
ently painful ulcers in the oral mucous mem- destruction by infection or disease.
brane that are usually self-limiting. The cause is Apoptosis, first identified in 1972, is
unknown and treatment is symptomatic. involved in biological activities including
embryonic development, ageing and many dis-
Apicectomy eases. Its importance to the bodys many
Apicectomy is the minor operation carried out physiological and pathological processes has
to try to save a tooth which has an ABSCESS on it only fairly recently been understood, and
or which does not respond to root treatment. In research into apoptosis is proceeding apace.
this, the abscess and the APEX of the tooth are In adults, around 10 billion cells die each day
removed. a figure which balances the number of cells
 Appetite 51

arising from the bodys stem-cell populations may become compromised and the wall
(see STEM CELL). Thus, the bodys normal become gangrenous. Eventually the appendix A
HOMEOSTASIS is regulated by apoptosis. As a may rupture, giving rise to a localised abscess in
person ages, apoptopic responses to cell DNA the abdomen or, more rarely, free pus within
damage may be less effectively controlled and so the abdomen which causes generalised PERI-
result in more widespread cell destruction, TONITIS. Rupture of the appendix is a serious
which could be a factor in the onset of complication and the patient may be severely
degenerative diseases. If, however, apoptopic unwell. Surgeons recognise that in order to
responses become less sensitive, this might con- make sure patients with appendicitis do not
tribute to the uncontrolled multiplication of progress to peritonitis, a certain percentage of
cells that is typical of cancers. Many diseases are normal appendixes are removed when clinical
now associated with changed cell survival: signs are suspicious but not diagnostic of
AIDS (see AIDS/HIV); ALZHEIMERS DISEASE and disease.
PARKINSONISM; ischaemic damage after coron-
ary thrombosis (see HEART, DISEASES OF) and Treatment The best treatment is prompt
STROKE; thyroid diseases (see THYROID GLAND, surgical removal of the diseased appendix, usu-
DISEASES OF); and AUTOIMMUNE DISORDERS. ally with antibiotic cover. If performed early,
Some cancers, autoimmune disorders and viral before rupture occurs, APPENDICECTOMY is
infections are associated with reduced or normally straightforward and recovery swift. If
inhibited apoptosis. Anticancer drugs, GAMMA the appendix has already ruptured and there is
RAYS and ULTRAVIOLET RAYS (UVR) initiate abscess formation or free intra-abdominal pus,
apoptosis. Other drugs for example, NON- surgery is still the best treatment but post-
STEROIDAL ANTI-INFLAMMATORY DRUGS operative complications are more likely, and full
(NSAIDS) alter the process of apoptosis. recovery may be slower.
Research is in train to harness new knowledge
about apoptosis for the development of new Appendix
treatments and modifications of existing ones A term applied to the appendages of several hol-
for serious disorders such as cancer and low organs: for example, the larynx has two
degenerative nervous diseases. pouches called appendices, and the epiploic
appendices are the tags of fat that hang from the
Appendicectomy exterior part of the large intestine. The com-
Appendicectomy, or appendectomy, is the monest application, however, is to the vermi-
operation for the removal of the vermiform form appendix of the large intestine. This is a
appendix in the ABDOMEN (see APPENDICITIS). short, slim, blind-ended tube up to 10 cm long
attached to the caecum (a pouch at the start of
Appendicitis the large intestine). Its function is unknown,
This is an inflammatory condition of the though it may once have had one in ancestral
APPENDIX, and is a common surgical emer- humans. It is, however, prone to inflammation
gency, affecting mainly adolescents and young and infection (see APPENDICITIS).
adults. It is usually due to a combination of
obstruction and infection of the appendix, and Appetite
has a variable clinical course ranging from epi- Appetite is the craving for the food necessary to
sodes of mild self-limiting abdominal pain to maintain the body and to supply it with suf-
life-threatening illness. Abdominal pain begin- ficient energy to carry on its functions. The
ning in the centre of the abdomen but which ultimate cause of appetite is a question of sup-
later shifts position to the right iliac fossa is the ply and demand in the muscles and various
classic symptom. The patient usually has organs, but the proximate cause is doubtful.
accompanying fever and sometimes nausea, Unlike hunger, it is probably an acquired,
vomiting, loss of appetite, diarrhoea, or even rather than an inborn, sensation. Whatever
constipation. The precise symptoms vary with other factors may be concerned, the tone of the
the exact location of the appendix within the STOMACH is of importance. Significant factors
abdomen. In some individuals the appendix in stimulating appetite are anticipation and the
may grumble with repeated mild attacks sight and smell of well-cooked food. Individuals
which resolve spontaneously. In an acute attack, who eat unsuitable substances such as faeces are
the inflammatory process begins first in the wall described as suffering from pica, which occurs
of the appendix but, if the disease progresses, sometimes during pregnancy, in children, and
the appendix can become secondarily infected often in mental disorders. The two chief
and pus may form within it. The blood supply disorders, however, are excessive increase of
 52 Approved Names for Medicines

appetite, and diminution or loss of appetite (see The condition is usually a consequence of dis-
A also EATING DISORDERS). ease in the brains parietal lobes, though
frontal-lobe disease may cause it. A person with
Excessive appetite may simply be a bad gait apraxia has normal power in the legs and
habit, due to habitual over-indulgence in good no abnormal signs suggesting cerebellar disease,
food and resulting in GOUT, OBESITY, etc. but cannot perform the normal act of walking
according to the other habits and constitution because of malfunction in the cerebrum.
of the person. It may also be a sign of DIABETES
MELLITUS or thyrotoxicosis (see under THYROID Apyrexia
GLAND, DISEASES OF). Absence of FEVER.

Diminished appetite is a sign common to Arachnodactyly

almost all diseases causing general weakness, Arachnodactyly, or MARFANS SYNDROME, is a
because the activity of the stomach and the congenital condition characterised by extreme
secretion of gastric juice fail early when vital length and slenderness of the fingers and toes
power is low. It is the most common sign of and, to a lesser extent, of the limbs and trunk;
DYSPEPSIA due to gastritis, and of cancer of the laxity of the ligaments; and dislocation of the
stomach. In some cases it is a manifestation of lens of the eye. The antero-posterior diameter
stress or strain such as domestic worry or dif- of the skull is abnormally long, and the jaw is
ficulties at work. Indeed, appetite seems to be prominent. There may also be abnormalities of
particularly susceptible to emotional disturb- the heart.
ances, as is evidenced by the linked conditions
of BULIMIA (pathological overeating) and ano- Arachnoid Membrane
rexia nervosa (pathological dieting) see also One of the membranes covering the brain and
EATING DISORDERS. spinal cord (see BRAIN). Arachnoiditis is the
name applied to inflammation of this
Approved Names for Medicines membrane.
The term used for names devised or selected by
the British Pharmacopoeia Commission for Arboviruses
new drugs. European Union law (1992) A heterogenous group of around 500 viruses,
requires the use of a Recommended Inter- which are transmitted to humans by ARTHRO-
national Non-proprietary Name (rINN) for PODS. Grouped in four families, they include
medicinal substances. In most cases the British the viruses of DENGUE and YELLOW FEVER
Approved Name (BAN) and rINN were the which are transmitted by mosquitoes.
same when the legislation was introduced;
where there were differences, the BAN was Arc Eye
modified to meet the new requirements. Damage to the corneal surface of the EYE caused
Pharmaceutical manufacturers usually give by ultraviolet light from arc welding. A painful
proprietary (brand) names to the drugs they condition, it usually heals if the eyes are covered
develop, though doctors in the NHS are with pads for a day or two. It can be prevented
expected to prescribe using approved non- by the proper use of protective goggles. A simi-
proprietary or generic titles. Most non- lar condition occurs in snow-blindness or when
proprietary titles are those in the European someone fails to protect the eyes when using
Pharmacopoeia, British Pharmacopoeia Com- suntan lamps.
mission or the British Pharmaceutical Codex.
The USA has its own legislation and arrange- Arcus Senilis
ments covering the naming and prescribing of See under EYE, DISORDERS OF.
medicines. (See PROPRIETARY NAME; GENERIC
DRUG; PATENT.) Arenaviruses
A group of viruses, so-called because under the
Apraxia electron microscope they have a sand-sprinkled
Apraxia, or dyspraxia, is the loss of ability to (Latin, arenosus) appearance. Among the dis-
make accurate skilled movements. The cause is eases in humans for which they are responsible
a disorder of the cerebral cortex of the BRAIN: are LASSA FEVER in West Africa, Argentinian
the patient is unable to coordinate his or her haemorrhagic fever (mortality rate 315 per
movements. Apraxia differs from clumsiness cent), a similar disease in Bolivia (mortality rate
resulting from muscular weakness, loss of sensa- 18 per cent), and lymphocytic choriomeningi-
tion or disease in the cerebellum (see BRAIN). tis, in which deaths are uncommon.
 Arteries 53

Areola inhibiting the action of many enzymes (see

A
Areola literally means a small space, and is the ENZYME) and also disrupts oxidative phos-
term applied to the red or dusky ring around phorylation by substituting for PHOSPHORUS.
the nipple, or around an inflamed part. Increase Clinical effects of acute poisoning range from
in the duskiness of the areola on the breast is an severe gastrointestinal effects to renal impair-
important early sign of pregnancy. ment or failure characterised by OLIGURIA,
HAEMATURIA, PROTEINURIA and renal tubular
Argyll Robertson Pupil necrosis. SHOCK, COMA and CONVULSIONS are
A condition (described originally by Dr Argyll reported, as are JAUNDICE and peripheral
Robertson) in which the pupils contract when NEUROPATHY. Chronic exposures are harder to
the eyes converge on a near object, but fail to diagnose as effects are non-specific: they include
contract when a bright light falls on the eye. It gastrointestinal disturbances, hyperpigmenta-
is found in several diseases, especially in loco- tion and HYPERKERATOSIS of skin, localised
motor ataxia and neurosyphilis, an advanced OEDEMA, ALOPECIA, neuropathy, PAR-
manifestation of SYPHILIS. AESTHESIA, HEPATOMEGALY and jaundice.
Management is largely supportive, particularly
Argyria ensuring adequate renal function. Concentra-
Argyria, or argyriosis, means the effect pro- tions of arsenic in urine and blood can be
duced by taking silver salts over a long period, measured and therapy instituted if needed. Sev-
and consists of a deep duskiness of the skin, eral CHELATING AGENTS are effective: these
especially of the exposed parts. include DMPS (2, 3-dimercapto-1-propane-
sulphonate), penicillamine and dimercaprol;
Aromatase Inhibitors DMPS is now agent of choice.
A group of drugs that stop the action of the
ENZYME, aromatase. This enzyme converts Artefact
androgens (see ANDROGEN) to OESTROGENS. If See ARTIFACT.
this conversion is inhibited, the concentrations
of oestrogens in the body are reduced so these Arteries
drugs operate against tumours, such as breast Arteries are vessels which convey oxygenated
cancer, that depend on oestrogen for their blood away from the heart to the tissues of the
growth. Aromatase inhibitors include anastra- body, limbs and internal organs. In the case of
zole and formestane, and they are usually pre- most arteries the blood has been purified by
scribed as second-line treatment after TAMOXI- passing through the lungs, and is consequently
FEN, the prime drug treatment for breast cancer. bright red in colour; but in the pulmonary
arteries, which convey the blood to the lungs, it
Arrhythmia is deoxygenated, dark, and like the blood in
Arrhythmia means any variation from the nor- veins.
mal regular rhythm of the heartbeat. The con- The arterial system begins at the left ventricle
dition is produced by some affection interfering of the heart with the AORTA, which gives off
with the mechanism which controls the beating branches that subdivide into smaller and
of the heart, and includes the following dis- smaller vessels. The final divisions, called
orders: sinus arrhythmia, atrial fibrillation, arterioles, are microscopic and end in a network
atrial flutter, heart block, extrasystoles, pulsus of capillaries which perforate the tissues like the
alternans, and paroxysmal atrial tachycardia, pores of a sponge and bathe them in blood that
ventricular tachycardia and ventricular fibrilla- is collected and brought back to the heart by
tion. (See HEART, DISEASES OF; ELECTRO- veins. (See CIRCULATORY SYSTEM OF THE
CARDIOGRAM (ECG).) BLOOD.)

Arsenic The chief arteries after the aorta and its

A metalloid with industrial use in glass, wood branches are:
preservative, herbicide, semiconductor manu- (1) the common carotid, running up each side
facture, and as an alloy additive. It may be a of the neck and dividing into the internal
component in alternative or traditional remed- carotid to the brain, and external carotid
ies both intentionally and as a contaminant. to the neck and face;
Common in the environment and in food, (2) the subclavian to each arm, continued by
especially seafood, arsenic is odourless and taste- the axillary in the armpit, and the brachial
less and highly toxic by ingestion, inhalation along the inner side of the arm, dividing at
and skin contact. It binds to sulphydryl groups the elbow into the radial and the ulnar,
 54 Arteries, Diseases of

which unite across the palm of the hand in arteries cause limb ischaemia (localised
A arches that give branches to the fingers; bloodlessness).
(3) the two common iliacs, in which the aorta Risk factors predisposing individuals to ath-
ends, each of which divides into the internal erosclerosis include age, male gender, raised
iliac to the organs in the pelvis, and the plasma cholesterol concentration, high blood
external iliac to the lower limb, continued pressure, smoking, a family history of athero-
by the femoral in the thigh, and the poplit- sclerosis, diabetes and obesity.
eal behind the knee, dividing into the
anterior and posterior tibial arteries to the Arteritis occurs in a variety of conditions
front and back of the leg. The latter passes that produce inflammation in the arteries.
behind the inner ankle to the sole of the Examples include syphilis now rare in Britain
foot, where it forms arches similar to those which produces inflammation of the aorta
in the hand, and supplies the foot and toes with subsequent dilatation (aneurysm forma-
by plantar branches. tion) and risk of rupture; giant cell arteritis
(temporal arteritis), a condition usually affect-
Structure The arteries are highly elastic, ing the elderly, which involves the cranial arter-
dilating at each heartbeat as blood is driven into ies and leads to headache, tenderness over the
them, and forcing it on by their resiliency (see temporal arteries and the risk of sudden blind-
PULSE). Every artery has three coats: (a) the ness; Takayasus syndrome, predominantly
outer or adventitia, consisting of ordinary affecting young females, which involves the aor-
strong fibrous tissue; (b) the middle or media, tic arch and its major branches, leading to the
consisting of muscular fibres supported by elas- absence of pulse in affected vessels; and polyar-
tic fibres, which in some of the larger arteries teritis nodosa, a condition causing multiple
form distinct membranes; and (c) the inner or small nodules to form on the smaller arteries.
intima, consisting of a layer of yellow elastic General symptoms such as fever, malaise,
tissue on whose inner surface rests a layer of weakness, anorexia and weight loss are accom-
smooth plate-like endothelial cells, over which panied by local manifestations of ischaemia
flows the blood. In the larger arteries the muscle (bloodlessness) in different parts of the body.
of the middle coat is largely replaced by elastic
fibres, which render the artery still more expan- Arteriography
sile and elastic. When an artery is cut across, the See ANGIOGRAPHY.
muscular coat instantly shrinks, drawing the
cut end within the fibrous sheath that sur- Arteriole
rounds the artery, and bunching it up, so that a A small artery (see ARTERIES).
very small hole is left to be closed by blood-clot.
(See HAEMORRHAGE.) Arterio-Venous Aneurysm
An abnormal communication between an
Arteries, Diseases of artery and a vein. It is usually the result of an
ARTERIES are the blood vessels that convey injury, such as a stab or a gunshot wound,
blood away from the heart to the tissues. The which involves both a neighbouring artery and
commonest cause of arterial disease is a degen- vein.
erative condition known as atherosclerosis. Less
commonly, inflammation of the arteries occurs; Arteritis
this inflammation is known as arteritis and Arteritis means inflammation of an artery (see
occurs in a variety of conditions. ARTERIES, DISEASES OF).

Atherosclerosis is due to the deposition of Arthralgia

CHOLESTEROL into the walls of arteries. The Pain in a joint in which there is no swelling or
process starts in childhood with the develop- other indication of ARTHRITIS.
ment of fatty streaks lining the arteries. In
adulthood these progress, scarring and calcify- Arthritis
ing to form irregular narrowings within the Arthritis refers to any condition of joints of the
arteries and eventually leading to blockage of limbs or spine associated with inflammatory or
the vessel. The consequence of the narrowing or structural change. It is distinguished from
blockage depends on which vessels are involved ARTHRALGIA which simply implies joint pain
diseased cerebral vessels cause strokes; coron- with or without any inflammatory or structural
ary vessels cause angina and heart attacks; renal change. The two main categories of arthritis are
vessels cause renal failure; and peripheral osteoarthritis, in which the primary change is
 Artifact (Artefact) 55

thought of as mechanical failure of articular car- organisms, such as scorpions, mites, ticks,
tilage; and rheumatoid arthritis, in which the spiders and centipedes (see also ARBOVIRUSES). A
primary problem is a chronic inflammation of
the synovial lining of joints, tendon sheaths and Arthroscope
bursae. Other, less common forms of inflamma- An endoscopic instrument (see ENDOSCOPE)
tory arthritis include psoriatic arthritis, Reiters that enables the operator to see inside a joint
syndrome, colitic arthritis and Behets syn- cavity and, if necessary, take a biopsy or carry
drome. Spondarthritis refers to an inflamma- out an operation.
tory arthritis with involvement of the spine and
is often associated with the HLA B27 tissue Arthroscopy
type. (See OSTEOARTHRITIS; RHEUMATOID Inspection of the interior of a joint (usually the
ARTHRITIS; RHEUMATIC FEVER.) knee) to diagnose any disorder there. The
instrument used is a type of ENDOSCOPE called
Arthrodesis an ARTHROSCOPE. The knee is often affected by
An operation for fixating the bones in a diseased conditions that are not easy to diagnose and are
joint in a given position so that the joint cannot not revealed by X-ray examination. Surgery can
be moved. It is usually done if pain and deform- be performed using arthroscopy and this
ity in a diseased joint caused, for instance, by reduces the time a patient has to be in hospital.
RHEUMATOID ARTHRITIS are so bad that they
cannot be relieved by drugs, PHYSIOTHERAPY, Arthrotomy
splinting or ARTHROPLASTY. Surgical exploration of a joint to examine the
contents or to drain PUS in SEPTIC ARTHRITIS.
Arthropathy
A term applied to any form of joint disease. Articular
Articular means anything connected with a
Arthroplasty joint: for example, articular rheumatism.
The use of metal or plastic components to
replace a joint or part of a joint. Arthroplasty Articulation
was first used in the 1930s to replace diseased Articulation is a term employed in two senses in
hip-joints and has been routinely used since the medicine, meaning either the enunciation of
1960s, enabling thousands of people, especially words and sentences, or the type of contact
the older generation, to resume normal life free between the surfaces of joints these surfaces
from pain and disability. Replacement of other are called articular surfaces.
joints for instance, knees, fingers, shoulders
and elbows has now become routine. (See Artifact (Artefact)
JOINTS, DISEASES OF and diagram.) A foreign body found in living tissue viewed
under a microscope. It is usually caused by
Arthropods faulty preparation of a specimen, with the
Arthropods are segmented invertebrates with result that disease or abnormality seems to be
jointed legs. They include a wide range of present.

Arthroplasty of right hip (front view) showing how the artificial metal head fits into the metal socket set
into the ischial part of the pelvis.
 56 Artificial Insemination

A Artificial Insemination pressure ventilation is mouth-to-mouth resusci-

In this method of fertilisation, SEMEN is col- tation (see APPENDIX 1: BASIC FIRST AID) where
lected either by the husband (AIH) or by a an individual blows his or her own expired gases
donor (AID) through masturbation and intro- into the lungs of a non-breathing person via the
duced into the cervix (neck of the womb) by mouth or nose. Similarly gas may be blown into
means of an instrument around the time of the lungs via a face mask (or down an endotra-
OVULATION. cheal tube) and a self-inflating bag or an anaes-
AIH is thought to be particularly useful for thetic circuit containing a bag which is inflated
men with retrograde ejaculation or erectile by the flow of fresh gas from an anaesthetic
IMPOTENCE. AID may be considered when the machine, gas cylinder, or piped supply. In all
partners sperm count is either very low or zero. these examples expiration is passive.
Insemination can be made with fresh or For more prolonged artificial ventilation it is
frozen semen. Donors should be tested for usual to use a specially designed machine or
sexually transmitted diseases and their identity ventilator to perform the task. The ventilators
remain unknown to the infertile couple. The used in operating theatres when patients are
pregnancy rate over six months is 5060 per anaesthetised and paralysed are relatively simple
cent. Artificial insemination is usually done at devices.They often consist of bellows which fill
specially staffed centres with facilities to store with fresh gas and which are then mechanically
semen and provide the individuals involved emptied (by means of a weight, piston, or com-
with appropriate counselling. Success rates are pressed gas) via a circuit or tubes attached to an
up to 70 per cent with fresh semen (used over a endotracheal tube into the patients lungs.
six-month period) and over 50 per cent with Adjustments can be made to the volume of
frozen semen. fresh gas given with each breath and to the
length of inspiration and expiration. Expiration
Artificial Intelligence (AI) is usually passive back to the atmosphere of the
The design and study of computer systems that room via a scavenging system to avoid
have properties resembling human intelligence, pollution.
such as natural language, problem-solving, and In intensive-care units, where patients are
analysis of novel situations. not usually paralysed, the ventilators are more
complex. They have electronic controls which
Artificial Joints allow the user to programme a variety of pres-
See ARTHROPLASTY. sure waveforms for inspiration and expiration.
There are also programmes that allow the
Artificial Kidney patient to breathe between ventilated breaths or
See DIALYSIS. to trigger ventilated breaths, or inhibit ventila-
tion when the patient is breathing.
Artificial Limbs and Other Parts Indications for artificial ventilation are when
See PROSTHESIS. patients are unable to achieve adequate respira-
tory function even if they can still breathe on
Artificial Respiration their own. This may be due to injury or disease
See APPENDIX 1: BASIC FIRST AID. of the central nervous, cardiovascular, or
respiratory systems, or to drug overdose. Arti-
Artificial Ventilation of the ficial ventilation is performed to allow time for
Lungs healing and recovery. Sometimes the patient is
When we breathe in, the outward movement of able to breathe but it is considered advisable to
the chest increases the volume of the lungs and control ventilation for example, in severe head
the pressure in them falls below that of the out- injury. Some operations require the patient to
side world. Therefore, air is drawn in auto- be paralysed for better or safer surgical access
matically. When we breathe out, some air exits and this may require ventilation. With lung
because of the normal elastic recoil of the lungs, operations or very unwell patients, ventilation
but we also force air out by using the muscles of is also indicated.
the chest and the DIAPHRAGM. Replicating this Artificial ventilation usually bypasses the
artificially involves using a device to produce physiological mechanisms for humidification of
intermittent positive or negative pressure venti- inspired air, so care must be taken to humidify
lation as described below. inspired gases. It is important to monitor the
efficacy of ventilation for example, by using
Intermittent positive pressure (IPP) blood gas measurement, pulse oximetry, and
The simplest form of intermittent positive- tidal carbon dioxide, and airways pressures.
 Ascites 57

Artificial ventilation is not without its haz- scribed. About 900 people a year in the UK
ards. The use of positive pressure raises the claim compensation, and 600 of these for mes- A
mean intrathoracic pressure. This can decrease othelioma; most patients with asbestosis now
venous return to the heart and cause a fall in being diagnosed have it as a consequence of
CARDIAC OUTPUT and blood pressure. Positive- industrial practices used before 1970. The use
pressure ventilation may also cause PNEUMO- of asbestos is now strictly controlled and, when
THORAX, but this is rare. While patients are blue asbestos is found in old buildings, skilled
ventilated, they are unable to breathe and so workmen are employed to dispose of it.
accidental disconnection from the ventilator
may cause HYPOXIA and death. Ascariasis
Ascariasis is the disease produced by infestation
Negative-pressure ventilation is sel- with the roundworm Ascaris lumbricoides, also
dom used nowadays. The chest or whole body, known as the maw-worm. Superficially it
apart from the head, is placed inside an airtight resembles a large earthworm: the male measures
box. A vacuum lowers the pressure within the about 17 cm (7 inches) and the female 23 cm (9
box, causing the chest to expand. Air is drawn inches) in length. Ascariasis is a dirt disease,
into the lungs through the mouth and nose. At most prevalent where sanitation and cleanliness
the end of inspiration the vacuum is stopped, are lacking, particularly in the tropics and sub-
the pressure in the box returns to atmospheric, tropics. Consumption of food contaminated by
and the patient exhales passively. This is the the ova (eggs), especially salad vegetables, is the
principle of the iron lung which saved many commonest cause of infection. In children,
lives during the polio epidemics of the 1950s. infection is commonly acquired by crawling or
These machines are cumbersome and make playing on contaminated earth, and then suck-
access to the patient difficult. In addition, com- ing their fingers. After a complicated life-cycle
plex manipulation of ventilation is impossible. in the body the adult worms end up in the
intestines, whence they may be passed in the
Jet ventilation is a relatively modern form stools. A light infection may cause no symp-
of ventilation which utilises very small tidal toms. A heavy infection may lead to colic, or
volumes (see LUNGS) from a high-pressure even obstruction of the gut. Occasionally a
source at high frequencies (20200/min). First worm may wander into the stomach and be
developed by physiologists to produce low vomited up.
stable intrathoracic pressures whilst studying
CAROTID BODY reflexes, it is sometimes now Treatment Mebendazole is the drug of
used in intensive-therapy units for patients who choice in the UK, being given as a single dose.
do not achieve adequate gas exchange with con- It should be combined with hygienic measures
ventional ventilation. Its advantages are lower to break the cycle of autoinfection. All members
intrathoracic pressures (and therefore less risk of of the family require treatment. Other
pneumothorax and impaired venous return) ANTHELMINTICS include piperazine and
and better gas mixing within the lungs. pyrantel.

Arytenoid Ascaricides
The name applied to two cartilages in the Drugs used to treat ASCARIASIS, a disease caused
LARYNX. by an infestation with the parasitic worm
Ascaris lumbricoides. LEVAMISOLE, MEBENDA-
Asbestosis ZOLE and PIPERAZINE are all effective against
A form of PNEUMOCONIOSIS, in which wide- this parasite.
spread fine scarring occurs in the LUNGS, lead-
ing to severe breathing disability. The main Ascaris
hazard, however, is the risk of cancer (MES- A worldwide genus of parasitic nematode
OTHELIOMA) of the lung or PLEURA, or some- worms (see ASCARIASIS).
times of the ovary (see OVARIES). It is caused by
the inhalation of mainly blue or brown asbestos Ascites
dust, either during mining or quarrying, or in An accumulation of fluid in the abdomen. The
one of the many industries in which it is used causes include heart failure, CANCER, cirrhosis
for example, as an insulating material, in the of the liver (see under LIVER, DISEASES OF), and
making of paper, cardboard and brake linings. infections. Treatment is directed at the under-
A person suffering from asbestosis is entitled to lying cause(s); if the amount of fluid is causing
compensation, as the disease is legally pro- discomfort, it should be drained off.
 58 Ascorbic Acid

A Ascorbic Acid an increasing number of public places are

Ascorbic acid, or vitamin C (see APPENDIX 5: becoming smoke-free. The charity has a small
VITAMINS), is a simple sugar found in living tis- headquarters in London from which further
sues its highest concentrations being in the information may be obtained, with other
adrenal cortex (see ADRENAL GLANDS) and the national and regional branches in Scotland,
eye. Stress and CORTICOTROPIN lead to a loss of Wales and Northern Ireland.
ascorbic acid from the adrenal cortex. Fresh
fruit and vegetables, particularly blackcurrants, Asparaginase
citrus fruits, berries and green vegetables, are Asparaginase is an ENZYME that breaks down
the richest dietary sources; it may also be syn- the amino acid (see AMINO ACIDS), asparagine.
thetically prepared. Ascorbic acid is easily elim- This is of no significance to most cells in the
inated from the diet by traditional methods of body as they can make asparagine from simpler
cooking, being very soluble in water and easily constituents. Certain tumours, however, are
destroyed by heat, alkalis, traces of copper or by unable to do this; therefore, if they cannot
an oxidase released by damage to plant tissues. receive ready-made supplies of the amino acid,
Deficiency may lead to SCURVY, traditionally they die. This property is utilised to treat acute
associated with sailors, among elderly people lymphoblastic LEUKAEMIA.
living alone or in poor communities living at
subsistence level. It has been claimed that large Aspartame
doses (12 g daily) will prevent the common Aspartame is an artificial sweetener, 200 times
cold, but few large controlled trials have been as sweet as sugar but without the bitter
carried out and it is inadvisable for people to aftertaste of saccharine.
dose themselves with large quantities of ascor-
bic acid, which may result in the formation of Aspergers Syndrome
oxalate stones in the urinary tract. (See also A lifelong personality disorder, evident from
VITAMIN.) childhood and regarded as a mild form of
AUTISM. Persons with the syndrome tend to
Asepsis have great difficulty with personal relationships.
A technique to produce a germ-free environ- They tend to take what is said to them as literal
ment to protect patients from infection. It is fact and have great difficulty in understanding
used for any procedure that might introduce irony, metaphors or even jokes. They appear
infection into the body and is essential for all shy with a distant and aloof character, emo-
surgery even minor procedures. Asepsis is tional rigidity and inability to adapt to new
achieved by ensuring that all people who come situations. They are often mocked and ill-
into contact with the patient scrub their hands treated at school by their fellows because they
and wear sterilised gowns with disposable masks appear unusual. Many people with Aspergers
and gloves. Operating-theatre air and equip- seem to take refuge in intense interests or hob-
ment must also be clean. An aseptic technique bies, often conducted to an obsessional degree.
is also necessary when caring for patients Many become skilled in mathematics and par-
whose immune system (see IMMUNITY) is sup- ticularly information technology. Frustration
pressed: one example is LEUKAEMIA, the treat- with the outside world which is so hard to
ment of which affects the immune system. comprehend may provoke aggressive outbursts
Asepsis is aimed at preventing infection; anti- when stressed.
sepsis is the use of chemicals to destroy germs
already on the body or in a wound (see Aspergillosis
ANTISEPTICS). A disease caused by invasion of the lung by the
fungus, Aspergillus fumigatus. The infection is
ASH acquired by inhalation of air-borne spores of
ASH, or Action on Smoking and Health, is a the fungus, which settle and grow in damaged
charity founded by the Royal College of Phys- parts of the lung such as healed tuberculous
icians in 1971 and supported by the Depart- cavities, abscesses, or the dilated bronchi of
ment of Health. It gathers information about BRONCHIECTASIS.
the dangers of smoking, which it disseminates
to the public. It also commissions surveys on Aspergillus
public attitudes to smoking and helps people to A group of fungi including the common
give up the habit. ASH has contributed sub- moulds. Several of these are capable of infecting
stantially to the cut in the number of smokers: the lungs and producing a disease resembling
six out of ten adults are now non-smokers, and pulmonary TUBERCULOSIS.
 Aspirin Poisoning 59

Asphyxia small amount of fluid may be drawn off for

A
Asphyxia means literally absence of pulse, but is diagnosis of its nature or origin. An instrument
the name given to the whole series of symptoms called an aspirator is used to remove blood and
which follow stoppage of breathing and of the fluid from a surgical-operation site for
hearts action. Drowning is one cause, but example, the abdomen or the mouth (in
obstruction of the AIR PASSAGES may occur as dentistry).
the result of a foreign body or in some diseases, PLEURISY with effusion is a condition requir-
such as CROUP, DIPHTHERIA, swelling of the ing aspiration, and a litre or more of fluid may
throat due to wounds or inflammation, be drawn off by an aspirator or a large syringe
ASTHMA (to a partial extent), tumours in the and needle. Chronic abscesses and tuberculous
chest (causing slow asphyxia), and the external joints may call for its use, the operation being
conditions of suffocation and strangling. Pla- done with a small syringe and hollow needle.
cing the head in a plastic bag results in PERICARDITIS with effusion is another condi-
asphyxia, and poisonous gases also cause tion in which aspiration is sometimes per-
asphyxia: for example, CARBON MONOXIDE formed. The spinal canal is aspirated by the
(CO) gas, which may be given off by a stove or operation of LUMBAR PUNCTURE. In children
charcoal brazier in a badly ventilated room, can the ventricles of the brain are sometimes simi-
kill people during sleep. Several gases, such as larly relieved from excess of fluid by piercing
sulphurous acid (from burning sulphur), the fontanelle (soft spot) on the infants head.
ammonia, and chlorine (from bleaching- (See HYDROCEPHALUS.)
powder), cause involuntary closure of the
entrance to the larynx, and thus prevent breath- Aspirin
ing. Other gases, such as nitrous oxide (or Aspirin or acetylsalicylic acid is a white crystal-
laughing-gas), chloroform, and ether, in poi- line powder which is used like sodium salicyl-
sonous quantity, stop the breathing by paralys- ate as a remedy for reducing inflammation
ing the respiration centre in the brain. and fever. Taken orally, it has some action in
relieving pain and producing sleep and is
Symptoms In most cases, death from therefore often used for headache and slighter
asphyxia is due to insufficiency of oxygen sup- degrees of insomnia (sleeplessness). Daily
plied to the blood. The first signs are rapid doses are now used in the prevention of cor-
pulse and gasping for breath. Next comes a onary thrombosis (see HEART, DISEASES OF);
rise in the blood pressure, causing throbbing the dose is 75300 mg. Aspirin should be
in the head, with lividity or blueness of the used with caution in people with DYSPEPSIA or
skin, due to failure of aeration of the blood, PEPTIC ULCER. (See also ANALGESICS.)
followed by still greater struggles for breath
and by general CONVULSIONS. The heart Aspirin Poisoning
becomes overdistended and gradually weaker, a ASPIRIN is a commonly available analgesic (see
paralytic stage sets in, and all struggling and ANALGESICS) which is frequently taken in over-
breathing slowly cease. When asphyxia is due dose. Clinical features of poisoning include nau-
to charcoal fumes, coal-gas, and other narcotic sea, vomiting, TINNITUS, flushing, sweating,
influences, there is no convulsive stage, and HYPERVENTILATION, DEHYDRATION, deafness
death ensues gently and may occur in the and acid-base and electrolyte disturbances (see
course of sleep. ELECTROLYTES). In more severe cases individuals
may be confused, drowsy and comatose. Rarely,
Treatment So long as the heart continues to renal failure (see KIDNEYS, DISEASES OF), PUL-
beat, recovery may be looked for with prompt MONARY OEDEMA or cardiovascular collapse
treatment. The one essential of treatment is to occur. Severe toxicity may be delayed, as absorp-
get the impure blood aerated by artificial respir- tion of the drug may be prolonged due to the
ation. Besides this, the feeble circulation can be formation of drug concretions in the stomach.
helped by various methods. (See APPENDIX 1: Treatment involves the repeated administration
BASIC FIRST AID Choking; Cardiac/respiratory of activated CHARCOAL, monitoring of concen-
arrest.) tration of aspirin in the blood, and correction of
acid-base and electrolyte imbalances. In more
Aspiration severely poisoned patients, enhanced excretion
Aspiration means the withdrawal of fluid or of the drug may be necessary by alkalinising the
gases from the natural cavities of the body or urine (by intravenous administration of sodium
from cavities produced by disease. It may be bicarbonate see under SODIUM) or
performed for curative purposes; alternatively, a HAEMODIALYSIS.
 60 Assisted Conception

A Assisted Conception (neck of the womb). Pregnancy should then

(Further information about the subject and the proceed normally. About one in five IVF preg-
terms used can be found at http:// nancies results in the birth of a child. The suc-
www.hfea.gov.uk/glossary) cess rate is lower in women over 40.
This technique is used when normal
methods of attempted CONCEPTION or ARTI- Indications In women with severely dam-
FICIAL INSEMINATION with healthy SEMEN have aged FALLOPIAN TUBES, IVF offers the only
failed. In the UK, assisted-conception pro- chance of pregnancy. The method is also used
cedures are governed by the Human Fertilisa- in couples with unexplained infertility or with
tion & Embryology Act 1990, which set up the male-factor infertility (where sperms are
Human Fertilisation & Embryology Authority abnormal or their count low). Women who
(HFEA). have had an early or surgically induced MENO-
PAUSE can become pregnant using donor eggs.
Human Fertilisation & Embryology A quarter of these pregnancies are multiple
Act 1990 UK legislation was prompted by that is, produce twins or more. Twins and trip-
the report on in vitro fertilisation produced by a lets are more likely to be premature. The main
government-appointed committee chaired by danger of ovarian stimulation for IVF is hyper-
Baroness Warnock. This followed the birth, in stimulation which can cause ovarian cysts. (See
1978, of the first test-tube baby. OVARIES, DISEASES OF.)
This Act allows regulation monitoring of all
treatment centres to ensure that they carry out Gamete intrafallopian transfer (GIFT)
treatment and research responsibly. It covers Another method of helping infertile couples. In
any fertilisation that uses donated eggs or sperm over half of women diagnosed as infertile, the
(called gametes) for example, donor insemin- Fallopian tubes are normal, and in many it is
ation or embryos (see EMBRYO) grown outside unknown why they cannot conceive although
the human body (known as licensed treatment). some have ENDOMETRIOSIS.
The Act also covers research on human embryos Eggs are obtained and mixed with the
with especial emphasis on foolproof labelling partners semen, then introduced into the
and immaculate data collection. womans Fallopian tubes for fertilisation to
take place. The fertilised egg travels to the
Human Fertilisation & Embryology uterus where IMPLANTATION occurs and preg-
Authority (HFEA) Set up by the UK gov- nancy proceeds. A variation of GIFT is zygote
ernment following the Warnock report, the intrafallopian transfer (ZIFT) in which early
Authoritys 221 members inspect and license development of the fertilised eggs happens in
centres carrying out fertilisation treatments the laboratory before the young embryo is
using donated eggs and sperm. It publishes a transferred to the Fallopian tubes. GIFT is
code of practice advising centres on how to best used in couples with unexplained infertil-
conduct their activities and maintains a register ity or with minor degrees of male or female
of information on donors, patients and all cervical factor infertility. The success rate is
treatments. It also reviews routinely progress about 17 per cent. (See also ARTIFICIAL IN-
and research in fertility treatment and the SEMINATION.)
attempted development of human CLONING.
Cloning to produce viable embryos (repro- Association
ductive cloning) is forbidden, but limited In statistical terms, this represents two separate
licensing of the technique is allowed in special- events apparently occurring together. Associ-
ist centres to enable them to produce cells for ation does not necessarily mean cause and
medical treatment (therapeutic cloning). effect. For example, if a researcher finds that
children wearing bicycle helmets have fewer
In vitro fertilisation (IVF) In this tech- injuries, this could imply that helmets protect
nique, the female partner receives drugs to them (cause and effect) or just that more careful
enhance OVULATION. Just before the eggs are children tend to be those who wear helmets
released from the ovary (see OVARIES), several (association).
ripe eggs are collected under ULTRASOUND
guidance or through a LAPAROSCOPE. The eggs Astereognosis
are incubated with the prepared sperm. About Astereognosis means the loss of the capacity to
40 hours later, once the eggs are fertilised, two recognise the nature of an object by feeling it,
eggs (three in special circumstances) are trans- and indicates a lesion (e.g. tumour) of the
ferred into the mothers UTERUS via the cervix brain.
 Asthma 61

Asthenia animal dander are the commonest problems.

A
A traditional term meaning lack of strength. Occupational factors such as grain dusts, hard-
metals fumes and chemicals in the plastic and
Asthenopia paint industry are important in some adults.
Asthenopia means a sense of weakness in the Viral infections are another common trigger,
eyes, coming on when they are used. As a rule it especially in young children.
is due to long-sightedness, slight inflammation, The prevalence of asthma appears to be on
or weakness of the muscles that move the eyes. the increase in most countries. Several factors
(See VISION.) have been linked to this increase; most import-
ant may be the vulnerability of the immature
Asthma immune system (see IMMUNITY) in infants.
Asthma is a common disorder of breathing High exposure to allergens such as house-dust
characterised by widespread narrowing of mite early in life may prime the immune sys-
smaller airways within the lung. In the UK the tem, while reduced exposure to common viral
prevalence among children in the 512 age infections may delay the maturation of the
group is around 10 per cent, with up to twice immune system. In addition, maternal smoking
the number of boys affected as girls. Among in pregnancy and infancy increases the risk.
adults, however, the sex incidence becomes
about equal. The main symptom is shortness of Clinical course The major symptoms of
breath. A major feature of asthma is the revers- asthma are breathlessness and cough. Occasion-
ibility of the airway-narrowing and, con- ally cough may be the only symptom, especially
sequently, of the breathlessness. This variability in children, where night-time cough may be
in the obstruction may occur spontaneously or mistaken for recurrent infection and treated
in response to treatment. inappropriately with antibiotics.
The onset of asthma is usually in childhood,
Cause Asthma runs in families, so that par- but it may begin at any age. In childhood, boys
ents with asthma have a strong risk of having are affected more often than girls but by adult-
children with asthma, or with other atopic (see hood the sex incidence is equal. Children who
ATOPY) illnesses such as HAY FEVER or eczema have mild asthma are more likely to grow out of
(see DERMATITIS). There is therefore a great deal the condition as they go through their teenaged
of interest in the genetic basis of the condition. years, although symptoms may recur later.
Several GENES seem to be associated with the The degree of airway-narrowing, and its
condition of atopy, in which subjects have a change with time and treatment, can be moni-
predisposition to form ANTIBODIES of the IgE tored by measuring the peak expiratory flow
class against allergens (see ALLERGEN) they with a simple monitor at home a peak-flow
encounter especially inhaled allergens. meter. The typical pattern shows the peak
The allergic response in the lining of the air- flow to be lowest in the early morning and this
way leads to an inflammatory reaction. Many morning dipping is often associated with dis-
cells are involved in this inflammatory process, turbance of sleep.
including lymphocytes, eosinophils, neutro- Acute exacerbations of asthma may be pro-
phils and mast cells. The cells are attracted and voked by infections or allergic stimuli. If they
controlled by a complex system of inflamma- do not respond quickly and fully to medication,
tory mediators. The inflamed airway-wall pro- expert help should be sought urgently since
duced in this process is then sensitive to further oxygen and higher doses of drugs will be neces-
allergic stimuli or to non-specific challenges sary to control the attack. In a severe attack the
such as dust, smoke or drying from the breathing rate and the pulse rate rise and the
increased respiration during exercise. Recogni- chest sounds wheezy. The peak-flow rate of air
tion of this inflammation has concentrated into the lungs falls. Patients may be unable to
attention on anti-inflammatory aspects of talk in full sentences without catching their
treatment. breath, and the reduced oxygen in the blood in
Continued inflammation with poor control very severe attacks may produce the blue colour
of asthma can result in permanent damage to of CYANOSIS in the lips and tongue. Such acute
the airway-wall such that reversibility is reduced attacks can be very frightening for the patient
and airway-narrowing becomes permanent. and family.
Appropriate anti-inflammatory therapy may Some cases of chronic asthma are included
help to prevent this damage. in the internationally agreed description
Many allergens can be important triggers of CHRONIC OBSTRUCTIVE PULMONARY DISEASE
asthma. House-dust mite, grass pollen and (COPD) a chronic, slowly progressive disorder
 62 Astigmatism

characterised by obstruction of the airflow Advice and support for research into asthma
A persisting over several months. is provided by the National Asthma Campaign.
See www.brit-thoracic.org.uk
Treatment The first important consideration
in the treatment of asthma is avoidance of pre- Prognosis Asthma is diagnosed in 1520 per
cipitating factors. When this is a specific animal cent of all pre-school children in the developed
or occupational exposure, this may be possible; world. Yet by the age of 15 it is estimated that
it is however more difficult for house-dust mite fewer than 5 per cent still have symptoms. A
or pollens. Exercise-induced asthma should be study in 2003 reported on a follow-up of per-
treated adequately rather than avoiding sons born in 19723 who developed asthma
exercise. and still had problems at the age of nine. By the
Desensitisation injections using small quan- time these persons were aged 26, 27 per cent
tities of specific allergens are used widely in were still having problems; around half of that
some countries, but rarely in the UK as they are number had never been free from the illness
considered to have limited value since most and the other half had apparently lost it for a
asthma is precipitated by many stimuli and few years but it had returned.
controlled adequately with simple treatment.
There are two groups of main drugs for the Astigmatism
treatment of asthma. The first are the broncho- An error of refraction in the EYE due to the
dilators which relax the smooth muscle in the cornea (the clear membrane in front of the eye)
wall of the airways, increase their diameter and being unequally curved in different directions,
relieve breathlessness. The most useful agents so that rays of light in different meridians can-
are the beta adrenergic agonists (see ADRENER- not be brought to a focus together on the retina.
GIC RECEPTORS) such as salbutamol and terbu- The curvature, instead of being globular, is egg-
taline. They are best given by inhalation into shaped, longer in one axis than the other. The
the airways since this reduces the general side- condition causes objects to seem distorted and
effects from oral use. These drugs are usually out of place, a ball for instance looking like an
given to reverse airway-narrowing or to prevent egg, a circle like an ellipse. The condition is
its onset on exercise. However, longer-acting remedied by suitable spectacles of which one
inhaled beta agonists such as salmeterol and surface forms part of a cylinder. A hard contact
formoterol or the theophyllines given in tablet lens may be fitted to achieve an evenly curved
form can be used regularly as prevention. The surface. Astigmatism may be caused by any dis-
beta agonists can cause TREMOR and PALPITA- ease that affects the shape of the cornea for
TION in some patients. example, a meibomian cyst (a swollen
The second group of drugs are the anti- sebaceous gland in the eyelid) may press on the
inflammatory agents that act to reduce inflam- cornea and distort it.
mation of the airway. The main agents in this
group are the CORTICOSTEROIDS. They must be Astroviruses
taken regularly, even when symptoms are Small round viruses (see VIRUS) with no distinct-
absent. Given by inhalation they have few side- ive features, which have been isolated from the
effects. In acute attacks, short courses of oral stools of infants with gastroenteritis (see DIAR-
steroids are used; in very severe disease regular RHOEA). Most adults have antibodies against
oral steroids may be needed. Other drugs have a these viruses; this suggests that infection is
role in suppressing inflammation: sodium cro- common. There is no treatment.
moglycate has been available for some years and
is generally less effective than inhaled steroids. Asymptomatic
Newer agents directed at specific steps in the The lack of any symptoms of disease, whether
inflammatory pathway, such as leukotriene or not a disease is present.
receptor-antagonists, are alternative agents.
Treatment guidelines have been produced by Asynergia
various national and international bodies, such The absence of harmonious and coordinated
as the British Thoracic Society. Most have set movements between muscles having opposite
out treatment in steps according to severity, actions for example, the flexors and extensors
with objectives for asthma control based on of a joint. Asynergia is a sign of disease of the
symptoms and peak flow. Patients should have a nervous system.
management plan that sets out their regular
treatment and their appropriate response to Asystole
changes in their condition. Arrest of the action of the heart.
 At-Risk Register 63

Atavism Athrombia A
The principle of inheritance of disease or bodily An inherited disorder in which there is a defect
characters from grandparents or remoter ances- of blood-clotting caused by a deficiency in the
tors, the parents not having been affected by formation of thrombin (see COAGULATION).
these.
Atlas
Ataxia The first cervical vertebra. (See SPINAL
Loss of coordination, though the power neces- COLUMN.)
sary to make the movements is still present.
Thus an ataxic person may have a good grip in Atony
each hand but be unable to do any fine move- Absence of tone or vigour in muscles and other
ments with the fingers; or, if the ataxia be in organs.
the legs, the person throws these about a great
deal in walking while still being able to lift the Atopy
legs and take steps quite well. This is due to a Atopy, meaning out of place, is a form of hyper-
sensory defect or to disease of the cerebellum. sensitivity characterised amongst other fea-
(See FRIEDREICHS ATAXIA; LOCOMOTOR tures by a familial tendency. It is due to the
ATAXIA.) propensity of the affected individual to produce
large amounts of reagin ANTIBODIES which
Atelectasis stick to MAST CELLS in the mucosa, so that
Collapse of a part of the lung, or failure of the when the ANTIGEN is inhaled, HISTAMINE is
lung to expand at birth. released from the mast cell. Atopy is the condi-
tion responsible for ASTHMA and HAY FEVER (see
also ALLERGY). It is estimated that 10 per cent of
Atenolol the human race is subject to atopy. (See also
One of several BETA-ADRENOCEPTOR-
DERMATITIS.)
BLOCKING DRUGS used in the treatment of high
blood pressure, ANGINA and ARRHYTHMIA. One
of its practical advantages is that only one dose
Atresia
The absence of a natural opening, or closure of
a day need be taken. Atenolol, being a beta-
it by a membrane. Thus atresia may be found in
blocking drug, may precipitate ASTHMA an
newborn infants, preventing the bowels from
effect that may be dangerous. Among the
moving. In young girls after puberty, absence of
side-effects are fatigue and disturbed sleep.
the menstrual flow may be due to such a
malformation at the entrance to the VAGINA.
Atheroma
Degenerative changes in the inner and middle Atrial Natriuretic Peptide
coats of arteries. (See ARTERIES, DISEASES OF.) The atria (see ATRIUM) of the heart contain pep-
tides with potent diuretic and vasodilating
Atherosclerosis properties. It has been known since 1980 that
A form of arteriosclerosis, in which there is fatty extracts of human atria have potent diuretic
degeneration of the middle coat of the arterial and natriuretic effects in animals (see DIURET-
wall. (See ARTERIES, DISEASES OF.) ICS). In 1984 three polypeptide species
were isolated from human atria and were
Athetosis called alpha, beta and gamma human atrial
Athetosis is the name for slow, involuntary natriuretic peptides. Plasma concentration of
writhing and repeated movements of the face, immunoreactive atrial natriuretic peptide can
tongue, hands and feet, caused by disease of the now be measured: the levels are low in healthy
brain. It is usually a manifestation of CEREBRAL subjects and are increased in patients with con-
PALSY. Drugs used to treat PARKINSONISM can gestive heart failure. Infusion of the peptides
also cause athetosis. reduces blood pressure and causes a natriuresis
and diuresis.
Athletes Foot
A somewhat loose term applied to a skin erup- Atrial Septal Defect
tion on the foot, usually between the toes. It is See HEART, DISEASES OF Congenital heart
commonly due to RINGWORM, but may be due disease.
to other infections or merely excessive sweating
of the feet. It usually responds to careful foot At-Risk Register
hygiene and the use of antifungal powder. See RISK REGISTER.
 64 Atrium

A Atrium Attention Deficit Disorder

(Plural: atria.) Atrium is the name now given to (Hyperactivity Syndrome)
the two upper cavities of the HEART. These used A lifelong disorder characterised by overactive
to be known as the auricles of the heart. The behaviour, short attention span and poor con-
term is also applied to the part of the ear centration. It is thought to be caused by a
immediately internal to the drum of the ear. minor abnormality that affects the part of the
brain that allows us to concentrate and focus on
Atrophy tasks. Some scientists have suggested that it may
Atrophy occurs when normal tissue, an organ be caused by particular foods, particularly pro-
or even the whole body wastes because the con- cessed foods containing artificial additives, and
stituent cells die. Undernourishment, disease, recommend special diets. In some countries,
injury, lack of use or AGEING may cause atro- attention deficit disorder is diagnosed in up to a
phy. Muscular atrophy occurs in certain neuro- tenth of all children; this may reflect differences
logical diseases such as POLIOMYELITIS or MUS- in paediatric practice and diagnosis rather than
CULAR DYSTROPHY. The ovary (see OVARIES) a real variation in prevalence of the disorder.
atrophies at the MENOPAUSE. (See also MUSCLES, Behaviour therapy is the main treatment. Those
DISORDERS OF.) children with very severe symptoms of restless-
ness, short attention span and disturbed
Atropine behaviour may respond to additional treatment
Atropine is the active principle of belladonna, with methylphenidate (Ritalin). This is an
the juice of the deadly nightshade. Because of amphetamine-like drug that is thought to
its action in dilating the pupils, it was at one stimulate the part of the brain that is not work-
time used as a cosmetic to give the eyes a full, ing properly. Use of this drug has, however,
lustrous appearance. Atropine acts by antagon- been controversial.
ising the action of the PARASYMPATHETIC NER-
VOUS SYSTEM. It temporarily impairs vision by Audiogram
paralysing accommodative power (see ACCOM- A graph produced during hearing tests (with an
MODATION). It inhibits the action of some of audiometer) that shows the hearing threshold
the nerves in the AUTONOMIC NERVOUS SYS- the minimal audible loudness level for a range
TEM. The drug relaxes smooth muscle. It has of sound frequencies.
the effect of checking the activity of almost all
the glands of the body, including the sweat Audiometry
glands of the SKIN and the SALIVARY GLANDS The testing of hearing.
in the mouth. It relieves spasm by paralysing
nerves in the muscle of the intestine, bile ducts, Auditory Nerve
bladder, stomach, etc. It has the power, in mod- See VESTIBULOCOCHLEAR NERVE.
erate doses, of markedly increasing the rate of
the heartbeat, though by very large doses the Aura
heart, along with all other muscles, is paralysed The peculiar feeling which persons who are sub-
and stopped. ject to epileptic seizures (see EPILEPSY) experi-
ence just before the onset of an attack. It may be
Uses In eye troubles, atropine drops are used a sensation of a cold breeze, a peculiar smell, a
to dilate the pupil for more thorough examin- vision of some animal or person, or an undefin-
ation of the interior of the eye, or to draw the able sense of disgust. An aura gives warning that
iris away from wounds and ulcers on the centre a fit is coming and may enable a place of safety
of the eye. They also soothe the pain caused by or seclusion to be reached. It may also occur as a
light falling on an inflamed eye, and are further precursor to a MIGRAINE headache.
used to paralyse the ciliary muscle and so pre-
vent accommodative changes in the eye while Aural
the eye is being examined with the OPHTHAL- Relating to the ear.
MOSCOPE. Given by injection, atropine is used
before general ANAESTHESIA to reduce secre- Auricle
tions in the bronchial tree. The drug can also be A term applied both to the pinna or flap of the
used to accelerate the heart rate in BRADY- ear, and also to the ear-shaped tip of the atrium
CARDIA as a result of coronary thrombosis. of the heart.

Atropine Poisoning Auriscope

See ATROPINE; BELLADONNA POISONING. An instrument for examining the ear. The
 Autoimmunity 65

source of illumination may be incorporated Autoclave A

into the instrument, as in the electric auriscope, This is a very effective way of ensuring that
or it may be an independent light which is material (e.g. surgical dressings) is completely
reflected into the ear by means of a forehead sterilised, and that even the most resistant bac-
mirror. (See EAR, DISEASES OF.) teria with which it may be contaminated are
destroyed. Its use is based upon the fact that
Auscultation water boils when its vapour pressure is equal to
The method used by physicians to determine, the pressure of the surrounding atmosphere.
by listening, the condition of certain internal This means that if the pressure inside a closed
organs. The ancient physicians appear to have vessel is increased, the temperature at which
practised a kind of auscultation, by which water inside the vessel boils will rise above 100
they were able to detect the presence of air or degrees centigrade. By adjusting the pressure,
fluids in the cavities of the chest and almost any temperature for the boiling of the
abdomen. water will be obtained.
In 1819 the French physician, Laennec,
introduced the method of auscultation by Autogenous
means of the STETHOSCOPE. Initially a wooden Autogenous means self-generated and is the
cylinder, the stethoscope has evolved into a bin- term applied to products which arise within the
aural instrument consisting of a small expanded body. It is applied to bacterial vaccines manu-
chest-piece and two flexible tubes, the ends of factured from the organisms found in dis-
which fit into the ears of the observer. Various charges from the body and used for the treat-
modifications of the binaural stethoscope have ment of the person from whom the bacteria
been introduced. were derived.
Conditions affecting the lungs can often be
recognised by means of auscultation and the Autoimmune Disorders
stethoscope. The same is true for the heart, in A collection of conditions in which the bodys
which disease can, by auscultation, often be immune system (see IMMUNITY) attacks its own
identified with striking accuracy. But ausculta- tissues, identifying them as foreign substances.
tion is also helpful in the investigation of Genetic factors may play a part in this
aneurysms (see ANEURYSM) and certain diseases abnormal function, but the causes are not clear.
of the OESOPHAGUS and STOMACH. The stetho- The disorder may affect one organ (organ-
scope is also a valuable aid in the detection of specific) or type of cell, or several (non-organ-
some forms of uterine tumours, especially in specific). Among the autoimmune disorders are
the diagnosis of pregnancy. ADDISONS DISEASE; autoimmune haemolytic
anaemia and pernicious anaemia (see under
Autism ANAEMIA); autoimmune chronic active HEPA-
A disorder, thought to be caused by a brain TITIS; DIABETES MELLITUS; MYASTHENIA
abnormality, that leads to a lifelong inability to GRAVIS; RHEUMATOID ARTHRITIS; and SYS-
relate in an ordinary way to people and situ- TEMIC LUPUS ERYTHEMATOSUS (SLE).
ations. Autism is usually diagnosed before the
age of three. It is rare, affecting around 20 Treatment Any major deficiencies, such as
people in every 10,000, and is three times more thyroxin or insulin lack, should be corrected.
common in boys than in girls. The main fea- The activity of the immune system should then
tures are a profound inability to form social be reduced. CORTICOSTEROIDS and, in more
relationships, delayed speech development, and severe cases, strong immunosuppressant drugs
a tendency to perform repeated compulsive AZATHIOPRINE, CYCLOPHOSPHAMIDE or
actions or rituals. There is no cure at present, METHOTREXATE should be administered.
but behaviour therapy can help children to lead Treatment is difficult because of the need to
more normal lives. control the autoimmune condition without
damaging the bodys ability to combat other
Auto- diseases.
Prefix meaning self.
Autoimmunity
Autoantibody Autoimmunity is a reaction to an individuals
An antibody (see ANTIBODIES) produced by a own tissues (self-antigens see ANTIGEN) to
persons immune system (see IMMUNITY) that which tolerance has been lost (see IMMUNITY).
acts against the bodys own tissues, resulting in Autoantibodies are not necessarily harmful and
AUTOIMMUNITY. are commonly encountered in healthy persons.
 66 Autointoxication

Autoimmune disease ensues when the immune ation of the internal organs of a dead body. (See
A system attacks the target cells of the auto- NECROPSY.)
immune reaction.
Autosomal Dominant Gene
Autointoxication See under GENETIC DISORDERS.
Literally means self-poisoning. Any condition
of poisoning brought about by substances Auto-Suggestion
formed in or by the body. A self-induced receptive, hypnotic state which
is believed to improve the bodys ability to help
Autologous Blood Transfusion itself. Doctors have long realised that if they
See TRANSFUSION Transfusion of blood. suggested to a patient that a particular treat-
ment would work, it often did a type of pla-
Autolysis cebo effect. Some techniques now make use of
The disintegration and softening of dead cells this idea. For instance, people can be taught
brought about by enzymes (see ENZYME) in the muscular relaxation to control their anxiety
cells themselves. states the BIOFEEDBACK principle.

Automatism Avascular
The performance of acts without conscious Without a blood supply. Avascular necrosis is
will, as, for example, after an attack of epilepsy the death of a tissue because the blood supply
or concussion of the brain. In such conditions has been cut off.
the person may perform acts of which he or she
is neither conscious at the time nor has any Aversion Therapy
memory afterwards. It is especially liable to A form of psychological treatment in which
occur when persons suffering from epilepsy, such an unpleasant response is induced to his or
mental subnormality, or concussion consume her psychological aberration that the patient
alcoholic liquors. It may also occur following decides to give it up. Thus the victim of alco-
the taking of barbiturates or PSYCHEDELIC holism is given a drug that makes the sub-
DRUGS. There are, however, other cases in sequent drinking of alcoholic liquors so
which there are no such precipitatory factors. unpleasant, by inducing nausea and vomiting,
Thus it may occur following hypnosis, mental that he or she decides to give up drinking. (See
stress or strain, or conditions such as FUGUE or ALCOHOL; DISULFIRAM.) Aversion therapy may
somnambulism (see SLEEP). The condition is of help in the treatment of alcoholism, drug addic-
considerable importance from a legal point of tion, sexual deviations such as transvestism, and
view, because acts done in this state, and for compulsive gambling.
which the person committing them is not
responsible, may be of a criminal nature. Avitaminosis
According to English law, however, it entails The condition of a human being or an animal
complete loss of consciousness, and only then is deprived of one or more vitamins (see VITAMIN).
it a defence to an action for negligence. A lesser
impairment of consciousness is no defence. Avulsion
Forcible tearing away of one tissue from
Autonomic Nervous System another. For example, a tendon may be avulsed
Part of the nervous system which regulates the from the bone to which it is attached, or a nerve
bodily functions that are not under conscious may be injured and torn away avulsed from
control: these include the heartbeat, intestinal the tissue in which it runs.
movements, salivation, sweating, etc. The
autonomic nervous system consists of two main Axilla
divisions the SYMPATHETIC NERVOUS SYSTEM Anatomical name for the armpit.
and the PARASYMPATHETIC NERVOUS SYSTEM.
The smooth muscles, heart and most glands are Axis
connected to nerve fibres from both systems The name applied to the second cervical ver-
and their proper functioning depends on the tebra. (See SPINAL COLUMN.)
balance between these two. (See also NERVES;
NERVOUS SYSTEM.) Axon
Nerve fibre: an elongated projection of a nerve
Autopsy cell or NEURON(E) that carries an electrical
A POST-MORTEM EXAMINATION, or the examin- impulse to the tissue at the end of the axon.
 Azotaemia 67

Schematic diagram of autonomic nervous system. (Left) Sympathetic nerves leaving middle section of
spinal cord to connect via the vertebral ganglion (sympathetic trunk) to organs. (Right) Parasympathetic
nerves leaving the brain and lower spinal cord to connect to organs.

Large axons are covered by a sheath of insulat- of transplant operations (see TRANSPLANTA-
ing myelin which is interrupted at intervals by TION) by reducing the chances of the trans-
nodes of Lanvier, where other axons branch planted organ (e.g. the kidney) being rejected
out. An axon may be more than a metre long. It by the body. Azathioprine is also proving to
ends by branching into several filaments called be of value in the treatment of AUTOIMMUNE
telodendria, and these are in contact with DISORDERS.
muscle or gland membranes and other nerves
(see NERVE). Azoospermia
The condition characterised by lack of sperm-
Azathioprine atozoa (see SPERMATOZOON) in the SEMEN.
A CYTOTOXIC and an immunosuppressive
drug (see IMMUNOSUPPRESSION). In the first Azotaemia
of these capacities it is proving to be of value Azotaemia means the presence of UREA and
in the treatment of acute leukaemia. As an other nitrogenous bodies in greater concentra-
immunosuppressive agent it reduces the anti- tion than normal in the blood. The condition is
body response of the body (see ANTIBODIES), generally associated with advanced types of
and is thereby helping to facilitate the success kidney disease (see KIDNEYS, DISEASES OF).
 (see MENTAL ILLNESS) can sometimes result in

B chronic backache and should be considered if

no clear physical diagnosis can be made.
If back pain is severe and/or recurrent, pos-
sibly radiating around to the abdomen or down
the back of a leg (sciatica see below), or is
accompanied by weakness or loss of feeling in
Babinski Reflex the leg(s), it may be caused by a prolapsed
When a sharp body is drawn along the sole of intervertebral disc (slipped disc) pressing on a
the foot, instead of the toes bending down nerve. The patient needs prompt investigation,
towards the sole as usual, the great toe is turned including MRI. Resting on a firm bed or board
upwards and the other toes tend to spread can relieve the symptoms, but the patient may
apart. After the age of about two years, the pres- need a surgical operation to remove the disc and
ence of this reflex indicates some severe disturb- relieve pressure on the affected nerve.
ance in the upper part of the central nervous The nucleus pulposus the soft centre of the
system. The Babinski reflex may occur transi- intervertebral disc is at risk of prolapse under
ently during COMA or after an epileptic fit and the age of 40 through an acquired defect in the
need not indicate permanent damage. fibrous cartilage ring surrounding it. Over 40
this nucleus is firmer and slipped disc is less
Bacillus likely to occur. Once prolapse has taken place,
This is a big group (genus) of gram-positive (see however, that segment of the back is never
GRAMS STAIN) rod-like BACTERIA. Found quite the same again, as OSTEOARTHRITIS
widely in the air and soil commonly as spores develops in the adjacent facet joints. Stiffness
they feed on dead organic matter. As well as and pain may develop, sometimes many years
infecting and spoiling food, some are patho- later. There may be accompanying pain in the
genic to humans, causing, for example, legs: SCIATICA is pain in the line of the sciatic
ANTHRAX, conjunctivitis (see EYE, DISORDERS nerve, while its rarer analogue at the front of
OF) and DYSENTERY. They are also the source the leg is cruralgia, following the femoral nerve.
of some antibiotics (See under MICROBIOLOGY.) Leg pain of this sort may not be true nerve pain
but referred from arthritis in the spinal facet
Bacitracin joints. Only about 5 per cent of patients with
A polypeptide antibiotic, with a spectrum simi- back pain have true sciatica, and spinal surgery
lar to penicillin. It is not absorbed if taken is most successful (about 85 per cent) in this
orally but is valuable topically as an ointment in group.
conjunction with neomycin or polymyxin. When the complaint is of pain alone, surgery
is much less successful. Manipulation by
Backache physiotherapists, doctors, osteopaths or chiro-
Most people suffer from backache at times dur- practors can relieve symptoms; it is important
ing their lives, much of which has no identifi- first to make sure that there is not a serious
able cause non-specific back pain. This diag- disorder such as a fracture or cancer.
nosis is one of the biggest single causes of sick- Other local causes of back pain are osteo-
ness absence in the UKs working population. arthritis of the vertebral joints, ankylosing
Certain occupations, such as those involving spondylitis (an inflammatory condition which
long periods of sedentary work, lifting, bending can severely deform the spine), cancer (usually
and awkward physical work, are especially likely secondary cancer deposits spreading from a
to cause backache. Back pain is commonly the primary tumour elsewhere), osteomyelitis,
result of sporting activities. osteoporosis, and PAGETS DISEASE OF BONE.
Non-specific back pain is probably the result Fractures of the spine compressed fracture of a
of mechanical disorders in the muscles, liga- vertebra or a break in one of its spinous pro-
ments and joints of the back: torn muscles, cesses are painful and potentially dangerous.
sprained LIGAMENTS, and FIBROSITIS. These (See BONE, DISORDERS OF.)
disorders are not always easy to diagnose, but Backache can also be caused by disease else-
mild muscular and ligamentous injuries are where, such as infection of the kidney or
usually relieved with symptomatic treatment gall-bladder (see LIVER), inflammation of the
warmth, gentle massage, analgesics, etc. Some- PANCREAS, disorders in the UTERUS and PELVIS
times back pain is caused or worsened by or osteoarthritis of the HIP. Treatment is effected
muscle spasms, which may call for the use of by tackling the underlying cause. Among the
antispasmodic drugs. STRESS and DEPRESSION many known causes of back pain are:
 Bacteria 69

Mechanical and traumatic causes plants and animals including humans. Many
Congenital anomalies. are beneficial to the environment and other liv-
Fractures of the spine. ing organisms, but some cause harm to their
Muscular tenderness and ligament strain. hosts and can be lethal. B
Osteoarthritis. Bacteria are classified according to their
Prolapsed intervertebral disc. shape: BACILLUS (rod-like), coccus (spherical
Spondylosis. see COCCI), SPIROCHAETE (corkscrew and spiral-
shaped), VIBRIO (comma-shaped), and pleo-
Inflammatory causes morphic (variable shapes). Some are mobile,
Ankylosing spondylitis. possessing slender hairs (flagellae) on the sur-
Brucellosis. faces. As well as having characteristic shapes,
Osteomyelitis. the arrangement of the organisms is significant:
Paravertebral abscess. some occur in chains (streptococci) and some in
Psoriatic arthropathy. pairs (see DIPLOCOCCUS), while a few have a
Reiters syndrome. filamentous grouping. The size of bacteria
Spondyloarthropathy. ranges from around 0.2 to 5 m and the small-
Tuberculosis. est (MYCOPLASMA) are roughly the same size as
the largest viruses (poxviruses see VIRUS). They
Neoplastic causes are the smallest organisms capable of existing
Metastatic disease. outside their hosts. The longest, rod-shaped
Primary benign tumours. bacilli are slightly smaller than the human
Primary malignant tumours. erythrocyte blood cell (7 m).
Bacterial cells are surrounded by an outer
Metabolic bone disease capsule within which lie the cell wall and plasma
Osteomalacia. membrane; cytoplasm fills much of the interior
Osteoporosis. and this contains genetic nucleoid structures
Pagets disease. containing DNA, mesosomes (invaginations
of the cell wall) and ribosomes, containing
Referred pain RNA and proteins. (See illustration.)
Carcinoma of the pancreas. Reproduction is usually asexual, each cell
Ovarian inflammation and tumours. dividing into two, these two into four, and so
Pelvic disease. on. In favourable conditions reproduction can
Posterior duodenal ulcer. be very rapid, with one bacterium multiplying
Prolapse of the womb. to 250,000 within six hours. This means that
bacteria can change their characteristics by evo-
Psychogenic causes lution relatively quickly, and many bacteria,
Anxiety. including Mycobacterium tuberculosis and
Depression. Staphylococcus aureus, have developed resistance
People with backache can obtain advice from to successive generations of antibiotics
www.backcare.org.uk produced by man. (METHICILLIN-RESISTANT
STAPHYLOCOCCUS AUREUS (MRSA)) is a serious
Baclofen hazard in some hospitals.
A powerful muscle-relaxant used for patients Bacteria may live as single organisms or con-
with chronic severe spasticity increased gregate in colonies. In arduous conditions
muscle rigidity resulting from disorders such some bacteria can convert to an inert, cystic
as CEREBRAL PALSY, MULTIPLE SCLEROSIS (MS) or state, remaining in their resting form until the
traumatic partial section of the SPINAL CORD. environment becomes more favourable. Bac-
Important adverse effects include SEDATION, teria have recently been discovered in an inert
HYPOTONIA and DELIRIUM. state in ice estimated to have been formed 250
million years ago.
Bacteraemia Bacteria were first discovered by Antonj van
Bacteraemia is the condition in which BAC- Leewenhoek in the 17th century, but it was not
TERIA are present in the bloodstream. until the middle of the 19th century that Louis
Pasteur, the famous French scientist, identified
Bacteria bacteria as the cause of many diseases. Some act
(Singular: bacterium.) Simple, single-celled, as harmful PATHOGENS as soon as they enter a
primitive organisms which are widely distrib- host; others may have a neutral or benign effect
uted throughout the world in air, water, soil, on the host unless the hosts natural immune
 70 Bacteria

defence system is damaged (see IMMUNOLOGY) and KIDNEYS; by the vagina into the UTERUS
so that it becomes vulnerable to any previously and FALLOPIAN TUBES. Harmful bacteria then
well-behaved parasites. Various benign bacteria cause disease by producing poisonous endo-
B that permanently reside in the human body are toxins or exotoxins, and by provoking
called normal flora and are found at certain INFLAMMATION in the tissues for example,
sites, especially the SKIN, OROPHARYNX, COLON abscess or cellulitis. Many, but not all, bacterial
and VAGINA. The bodys internal organs are infections are communicable namely, spread
usually sterile, as are the blood and cerebro- from host to host. For example, tuberculosis is
spinal fluid. spread by airborne droplets, produced by
Bacteria are responsible for many human dis- coughing.
eases ranging from the relatively minor for In scientific research and in hospital labora-
example, a boil or infected finger to the tories, bacteria are cultured in special nutrients.
potentially lethal such as CHOLERA, PLAGUE or They are then killed, stained with appropriate
TUBERCULOSIS. Infectious bacteria enter the chemicals and suitably prepared for examin-
body through broken skin or by its orifices: by ation under a MICROSCOPE. Among the stain-
nose and mouth into the lungs or intestinal ing procedures is one first developed in the late
tract; by the URETHRA into the URINARY TRACT 19th century by Christian Gram, a Danish

(Top) bacterial cell structure (enlarged to about 30,000 times its real size). (Centre and bottom) the varying
shapes of different bacteria.
 Bagassosis 71

physician. His GRAMS STAIN enabled bacteria Bacteriuria

to be divided into those that turned blue The presence of unusual bacteria in the urine,
gram positive and those that turned red usually a sign of infection in the kidneys, blad-
gram negative. This straightforward test, still der or urethra. Normal urine usually contains B
used today, helps to identify many bacteria and some harmless bacteria; however, if bacterial
is a guide to which ANTIBIOTICS might be numbers in a cleanly caught mid-stream speci-
effective: for example, gram-positive bacteria men exceed 10,000 in each millilitre, that is
are usually more susceptible to penicillin G abnormal. Investigation is necessary to find a
than gram-negative organisms. cause and start treatment.
Infections caused by bacteria are commonly Patients found to have bacteriuria on
treated with antibiotics, which were widely SCREENING may never have consulted a doctor
introduced in the 1950s. However, the conflict but nearly all have a few symptoms, such as
between science and harmful bacteria remains frequency or urgency so-called covert
unresolved, with the overuse and misuse of bacteriuria.
antibiotics in medicine, veterinary medicine Men have longer urethras and fewer urinary
and the animal food industry contributing to tract infections (UTIs) than women. Risk fac-
the evolution of bacteria that are resistant to tors include diabetes mellitus, pregnancy,
antibiotics. (See also MICROBIOLOGY.) impaired voiding and genito-urinary malforma-
tions. Over 70 per cent of UTIs are due to E.
Bacterial Meningitis coli, but of UTIs in hospital patients, only 40
See MENINGITIS.
per cent are caused by E. coli.
Bactericide Treatment Patients should be encouraged to
Anything which kills BACTERIA; the term is, how-
drink plenty of water, with frequent urination.
ever, usually applied to drugs and antiseptics
Specific antibiotic therapy with trimethoprim
which do this. Hence bactericidal.
or amoxicillin may be needed.
Bacteriology
See MICROBIOLOGY. Bacteroides
A type of gram-negative (see GRAMS STAIN),
Bacteriophage anaerobic, rod-like bacteria. They are generally
A VIRUS which invades a bacterium (see BAC- non-motile and usually found in the alimentary
TERIA). Containing either single-stranded or and urogenital tracts of mammals. Often
double-stranded DNA or RNA, a particular present in the mouth in association with
phage generally may infect one or a limited periodontal disease (see TEETH, DISEASES OF).
number of bacterial strains or species. After
infection, once phage nucleic acid has entered Bacup
the host cell, a cycle may result whereby the Bacup stands for the British Association of
bacteria are programmed to produce viral com- Cancer United Patients and their families and
ponents, which are assembled into virus par- friends. It was founded by Dr Vicky Clement-
ticles and released on bacterial lysis (disintegra- Jones after she was treated for ovarian cancer,
tion). Other (temperate) phages induce a non- and it became fully operational on 31 October
lytic, or lysogenic, state, in which phage nucleic 1985. The aim of the Association is to provide
acid integrates stably into and replicates with an information service to cancer patients who
the bacterial chromosome. The relationship can want to know more about their illness or who
revert to a lytic cycle and production of new need practical advice on how to cope with it. It
phages. In the process the phage may carry does not seek to replace the traditional relation-
small amounts of donor bacterial DNA to a ship between the doctor and patient, nor does it
new host: the production of diphtheria toxin by recommend specific treatment for particular
Corynebacterium diphtheriae and of erythro- patients; rather, its aim is to help patients to
genic toxin by Streptococcus pyogenes are well- understand more about their illness so that they
known examples of this effect. can communicate more effectively and freely
with their medical advisers and their families
Bacteriostatic and friends.
A term applied to substances that stop bacterial See www.cancerbacup.org.uk
growth and cell division.
Bagassosis
Bacterium An industrial lung disease occurring in those
See BACTERIA. who work with bagasse, which is the name
 72 BAL

given to the broken sugar cane after sugar has floats away from the examining finger and then
been extracted from it. Bagasse, which contains bounces back on to it.
6 per cent silica, is used in board-making. The
B inhalation of dust causes an acute lung affec- Balsams
tion, and subsequently in some cases a chronic Substances which contain resins and benzoic
lung disease. (See ALVEOLITIS.) acid. Balsam of Peru, balsam of tolu, and Friars
balsam (compound tincture of benzoin) are the
BAL chief. They are traditional remedies given
BAL is the abbreviation for British Anti- internally for colds, and aid expectoration,
Lewisite. (See DIMERCAPROL.) while locally they are used to cover abrasions
and stimulate ulcers.
Balance
The ability to balance is essential for a person to BAN
stand, walk and run. Maintaining this ability is See BRITISH APPROVED NAMES.
a complex exercise of coordination dependent
on the brain, sensory and motor nerves, and Bandages
joints. There is a regular supply of information Pieces of material used to support injured parts
to the brain about the positions of various parts or to retain dressings in position. They come in
of the body and it responds with relevant various forms including elastic materials and
instructions to the motor parts of the body. plaster of Paris.
Eyes, the inner ear, skin and muscles all provide For more detailed information about ban-
information. The cerebellum (part of the brain) daging, the reader is referred to First Aid Man-
collates all the information and initiates action. ual, the authorised manual of the St Johns
Balance may be affected by disorders in the bal- Ambulance Association, St Andrews Ambu-
ancing mechanism of the inner ear (semi- lance Association and British Red Cross Society.
circular canals) such as MENIERES DISEASE, and
inflammation of the labyrinth (labyrinthitis). Baranys Test
Infection of the middle ear, such as otitis media A test for gauging the efficiency of the bal-
(see under EAR, DISEASES OF), can also disturb the ancing mechanism (the vestibular apparatus) by
ability to balance, sometimes accompanied by applying hot or cold air or water to the external
dizziness or VERTIGO. If the cerebellum is ear.
affected by disease a tumour or a stroke, for
example the result will be faulty muscular Barbers Itch
coordination leading to clumsiness and the See SYCOSIS.
inability to walk properly.
Barbiturates
Balanitis A group of drugs which depress the CENTRAL
Inflammation of the GLANS PENIS. Acute bal- NERVOUS SYSTEM by inhibiting the transmis-
anitis is associated with allergic DERMATITIS and sion of impulses between certain neurons. Thus
HERPES GENITALIS. Diabetics are at increased they cause drowsiness or unconsciousness
risk of non-specific secondary infections; if (depending on dose), reduce the cerebral meta-
recurrent balanitis occurs, circumcision is bolic rate for oxygen, and depress respiration.
sometimes advised. Their use as sedatives and hypnotics has largely
been superseded by more modern drugs which
Balantidiasis are safer and more effective. Some members of
A form of dysentery caused by a protozoon this group of drugs for instance, pheno-
known as Balantidium coli a common parasite barbitone have selective anticonvulsant prop-
in pigs, which are usually the source of infec- erties and are used in the treatment of GRAND
tion. It responds to metronidazole. MAL convulsions and status epilepticus (see EPI-
LEPSY). The short-acting drugs thiopentone and
Baldness methohexitone are widely used to induce
See ALOPECIA. general ANAESTHESIA. (See also DEPENDENCE.)

Ballottement Barium Sulphate

The technique of examining a fluid-filled part A radio-opaque white powder used in X-ray
of the body for the presence of a floating object. examinations of the stomach and gastrointest-
For example, a fetus can be pushed away by a inal tract. The barium sulphate may be swal-
finger inside the mothers vagina. The fetus lowed to enable the oesophagus, stomach and
 BCG Vaccine 73

small and large intestines to be assessed for dis- CAUTERY), LASER treatment or CRYOSURGERY.
orders such as ulceration, tumours, DIVERTICU- If the diagnosis is uncertain, a biopsy and
LAR DISEASE and polyps. It may also be inserted histological examination should be done.
into the RECTUM or descending COLON to B
investigate for possible disease. These pro- Basal Ganglion
cedures are usually done after endoscopy Grey matter near the base of the cerebral hemi-
examinations have been carried out. spheres, consisting of the corpus striatum
(caudate nucleus and lenticular nucleus [globus
Baroreceptor pallidus and putamen]), claustrum, and amyg-
Specialised nerve ending which lines certain daloid nucleus (see BRAIN). The basal ganglia are
blood vessels and acts as a stretch receptor in the involved in the subconscious regulation of vol-
carotid sinus, aortic arch, atria, pulmonary untary movement, and disorders in this region
veins and left ventricle. Increased pressure in cause DYSKINESIA.
these structures increases the rate of discharge
of the baroreceptors. This information is Basal Metabolism
relayed to the medulla and is important in the See METABOLISM.
control of blood pressure.
Basilic Vein
Barrier Creams The prominent vein which runs from near the
Substances, usually silicone-based, applied to bend of the elbow upwards along the inner side
the skin before work to prevent damage by irri- of the upper arm.
tants. They are also used in medicine for the
prevention of bedsores and nappy rash, for Basophilia
example. The blueish appearance under the microscope
of immature red blood corpuscles when stained
Barrier Nursing by certain dyes. This appearance, with the blue
The nursing of a patient suffering from an areas collected in points, is seen in lead poison-
infectious disease in such a way that the risk of ing and the condition is called punctate
their passing on the disease to others is reduced. basophilia. The term basophilia may also mean
Thus, precautions are taken to ensure that all an increase in the numbers of basophil cells in
infective matter such as stools, urine, sputum, the blood.
discharge from wounds, and anything that may
be contaminated by such infective matter (e.g. Bat Ears
nurses uniforms, bedding and towels) is so The term commonly applied to prominent ears.
treated that it will not convey the infection. (See The condition may be familial, but this is by no
NURSING.) means the rule. Strapping the ears firmly back
has no effect and is merely an embarrassment
Bartholins Glands to the child. Where the patient wishes it, the
Two small glands opening either side of the condition can be rectified by plastic surgery.
external vaginal orifice. Their secretions help to
lubricate the vulva, when a woman is sexually Bathers Itch
aroused. The glands may become infected and Bathers itch, also called schistosome DERMA-
very painful; sometimes an abscess develops TITIS, is the term given to a blotchy rash on the
and local surgery is required. Otherwise anti- skin occurring in those bathing in water which
biotics, analgesics and warm baths are usually is infested with the larvae of certain trematode
effective. worms known as schistosomes (see SCHISTO-
SOMIASIS). The worm is parasitic in snails. The
Basal Cell Carcinoma skin rash is caused by penetration of the skin by
The most common form of skin cancer. Its the free-swimming larval cercaria. Bathers itch
main cause is cumulative exposure to ultraviolet is common in many parts of the world.
light; most tumours develop on exposed sites,
chiefly the face and neck. It grows very slowly, BCG Vaccine
often enlarging with a raised, pearly edge, and BCG (Bacillus Calmette-Gurin) vaccine,
the centre may ulcerate (rodent ulcer). It does which was first introduced in France in 1908, is
not metastasise (see METASTASIS) and can be the only vaccine that has produced significant
cured by surgical excision or RADIOTHERAPY. immunity against the tubercle bacillus (see
Small lesions can also be successfuly treated by TUBERCULOSIS) and at the same time has proved
curettage and cauterisation (see ELECTRO- safe enough for use in human subjects. BCG
 74 BDA

vaccination is usually considered for the follow- The result is that patients who need inpatient
ing groups of people. (1) Schoolchildren: the care cannot always be admitted. The term bed-
routine programme in schools usually covers blockers is derogatory and should not be used.
B children aged between ten and 14. (2) Students,
including those in teacher training colleges. (3) Bed Bug
Immigrants from countries with a high preva- Bed bug, or Cimex lectularius, is a wingless,
lence of tuberculosis (TB). (4) Children and blood-sucking insect, parasitic on humans. It is
newborn infants born in the UK to parents a flat, rusty-brown insect, 5 mm long and 3 mm
from Group 3, or other newborns at parents wide, which has an offensive, never-forgotten
request. (5) Health workers, such as nurses, and smell and cannot fly. The average life is 36
others likely to be exposed to infection in their months, but it can live for a year without food.
work. (6) Veterinary workers who handle ani- The bed bug remains hidden during the day in
mals susceptible to TB. (7) Staff of prisons, cracks in walls and floors, and in beds. It does
residential homes and hostels for refugees and not transmit any known disease. Eggs hatch out
the homeless. (8) Household contacts of people into larvae in 610 days, which become adult
known to have active TB and newborn infants within about 12 weeks. A temperature of 44 C
in households where there is a history of the kills the adult in an hour. Various agents have
disease. (9) Those staying for more than one been used to disinfect premises, such as sulphur
month in high-risk countries. dioxide, ethylene oxide mixed with carbon
A pre-vaccination tuberculin test is necessary dioxide, hydrogen cyanide and heavy naphtha,
in all age-groups except newborn infants, and but insecticide is the most effective disinfecting
only those with negative tuberculin reactions agent.
are vaccinated. Complications are few and far
between. A local reaction at the site of vaccin- Bedpan
ation usually occurs between two and six weeks A container made of metal, fibre or plastic into
after vaccination, beginning as a small papule which a person confined to bed can defaecate
that slowly increases in size. It may produce a and, in the case of a female, urinate. Men use a
small ulcer. This heals after around two urinal a flask-shaped container to urinate.
months, leaving a small scar. (See IMMUNITY; Hospitals have special cleaning and sterilising
TUBERCULIN.) equipment for bedpans. They are much less
used than in the past because patients are
BDA encouraged to be mobile as soon as possible,
See BRITISH DENTAL ASSOCIATION. and also because bedside commodes are
preferred where this is practical.
Beclomethasone Dipropionate
One of the CORTICOSTEROIDS used as an aero- Bed Sores
See ULCER.
sol inhalant. It must be used regularly for its
best effect. Unlike systemic corticosteroids,
inhaled forms are much less likely to suppress
Bed-Wetting
See ENURESIS; NOCTURNAL ENURESIS.
adrenal-gland activity and have fewer side-
effects. Bee Stings
See BITES AND STINGS.
Bed Bath
A procedure for thoroughly washing a patient Behaviour Therapy
who is confined to bed. It helps to maintain a A form of psychiatric treatment based on learn-
healthy skin, especially over pressure-points ing theory. Symptoms are considered to be
such as elbows, buttocks and heels. An invalu- conditioned responses, and treatment is aimed
able preventive measure against the develop- at removing them, regardless of the underlying
ment of bed sores (see ULCER). diagnosis. Desensitisation, operant condition-
ing, and aversion therapy are examples of
Bed-Blocking behaviour therapy. (See MENTAL ILLNESS.)
The continued occupation of a hospital bed by
a patient who is fit to be discharged but requires Behets Syndrome
further care in a nursing home or in a com- This is a syndrome characterised by oral and
munity setting that cannot be arranged because genital ulceration, UVEITIS and ARTHROPATHY.
of lack of suitable facilities and/or funding. THROMBOPHLEBITIS is a common complica-
Bed-blocking has become a common phenom- tion, and involvement of the central nervous
enon in the NHS, particularly in the winter. system may occur.
 Benzodiazepines 75

Belching Benign
See ERUCTATION. Not harmful. Used especially to describe
tumours that are not malignant.
Belladonna Poisoning B
Atropa belladonna (deadly nightshade) is a rela- Bennetts Fracture
tively rare plant and severe poisoning is not Bennetts fracture so-called after an Irish sur-
common. The berries, which are black, ripen geon, Edward Hallaran Bennett (18371907)
from August to October and are the most is a longitudinal fracture of the first metacarpal
commonly ingested part of the plant. However, bone in the wrist, which also involves the
all parts of the plant are toxic. The berries con- carpo-metacarpal joint.
tain ATROPINE and other unidentified ALKAL-
OIDS, the leaves HYOSCINE and atropine, and
Benzedrine
the roots hyoscine. All these alkaloids have an Proprietary name for amphetamine sulphate (see
ANTICHOLINERGIC effect which may cause a
AMPHETAMINES).
dry mouth, dilated pupils with blurred vision,
TACHYCARDIA, HALLUCINATIONS and PYREXIA.
There may also be ATAXIA, agitation, disorienta-
Benzhexol
tion and confusion. In severe cases there may be One of the antimuscarinic (see ANTIMUSCARINE)
CONVULSIONS, COMA, respiratory depression
group of drugs used to treat PARKINSONISM.
and ARRHYTHMIA. Clinical effects may be Acting by correcting the relative central cholin-
delayed in onset for up to 12 hours, and pro- ergic excess resulting from DOPAMINE
longed for several days. Treatment is deficiency, the drug has a moderate effect,
supportive. reducing tremor and rigidity but with little
action on BRADYKINESIA. It has a synergistic (see
SYNERGIST) effect when used with LEVODOPA
Bells Palsy
Bells palsy, or idiopathic facial nerve palsy, and is useful in reducing SIALORRHOEA. Valu-
refers to the isolated paralysis of the facial able in treating cases of Parkinsonian side-
muscles on one or both sides. It is of unclear effects occurring with neuroleptic drugs. Tar-
cause, though damage to the seventh cranial, or dive DYSKINESIA is not improved and may be
FACIAL NERVE, possibly of viral origin, is
made worse.
thought likely. Occurring in both sexes at any There are few significant differences between
age, it presents with a facial pain on the affected the various antimuscarinic drugs available, but
side, followed by an inability to close the eye or some patients may tolerate one drug better than
smile. The mouth appears to be drawn over to another or find that they need to adjust their
the opposite side, and fluids may escape from drug regimen in relation to food.
the angle of the mouth. Lines of expression are
flattened and the patient is unable to wrinkle Benzocaine
the brow. Rare causes include mastoiditis, LYME Weak local anaesthetic found in some throat
DISEASE, and hypertension. lozenges, creams and gels. It may cause allergic
hypersensitivity.
Treatment Oral steroids, if started early,
increase the rate of recovery, which occurs in Benzodiazepines
over 90 per cent of patients, usually starting A large family of drugs used as HYPNOTICS,
after two or three weeks and complete within ANXIOLYTICS, TRANQUILLISERS, ANTICONVUL-
three months. Permanent loss of function with SANTS, premedicants, and for intravenous
facial contractures occurs in about 5 per cent of sedation. Short-acting varieties are used as hyp-
patients. Recurrence of Bells palsy is unusual. notics; longer-acting ones as hypnotics and
tranquillisers. Those with high lipid solubility
B Endorphin act rapidly if given intravenously.
A naturally occurring painkiller which is pro- Benzodiazepines act at a specific central-
duced by the PITUITARY GLAND as part of a pro- nervous-system receptor or by potentiating the
hormone (pre-pro-opianomelanocortin). It is action of inhibitory neuro-transmitters. They
an agonist at opioid receptors, and its release is have advantages over other sedatives by having
stimulated by pain and stress. (See some selectivity for anxiety rather than general
ENDORPHINS.) sedation. They are safer in overdose.
Unfortunately they may cause aggression,
Bends amnesia, excessive sedation, or confusion in the
See COMPRESSED AIR ILLNESS. elderly. Those with long half-lives or with
metabolites having long half-lives may produce
 76 Benzothiadiazines

a hangover effect, and DEPENDENCE on these is Treatment consists of large doses of vitamin B1
now well recognised, so they should not be pre- orally or intramuscularly; a diet containing
scribed for more than a few weeks. Commonly other vitamins of the B group; and rest.
B used benzodiazepines include nitrazepam, flu-
nitrazepam (a controlled drug), loprazolam, Infantile beriberi This is the result of
temazepam (a controlled drug) and chlorme- maternal thiamine deficiency; although the
thiazole, normally confined to the elderly. All mother is not necessarily affected, the breast-fed
benzodiazepines should be used sparingly baby may develop typical signs (see above).
because of the risk of dependence. Optic and third cranial, and recurrent laryngeal
nerves may be affected; encephalopathy can
Benzothiadiazines result in convulsions, coma and death.
See THIAZIDES.
Berylliosis
Benzyl Benzoate A disease of the lungs caused by the inhalation
An emulson that was widely used as a treatment of particles of beryllium oxide.
for SCABIES but is less effective and more irritant
than newer scabicides. It is not advised for use Beta Adrenoceptor
in children. See ADRENERGIC RECEPTORS.

Benzylpenicillin Beta-Adrenoceptor-Blocking
See PENICILLIN. Drugs
Also called beta blockers, these drugs interrupt
Bereavement the transmission of neuronal messages via the
The normal mental state associated with the bodys adrenergic receptor sites. In the HEART
death of a loved one, and the slow coming to these are called beta1 (cardioselective) receptors.
terms with that death. The well-recognised Another type beta2 (non-cardioselective)
stages of the bereavement reaction are: denial, receptors is sited in the airways, blood vessels,
bargaining, anger and acceptance. If bereave- and organs such as the eye, liver and pancreas.
ment symptoms are severe or prolonged, expert Cardioselective beta blockers act primarily on
counselling may help. Bereavement-like symp- beta1 receptors, whereas non-cardioselective
toms may occur after divorce, retirement or drugs act on both varieties, beta1 and beta2.
other life-changing experiences. (The neurotransmissions interrupted at the
beta-receptor sites through the body by the beta
Beriberi blockers are initiated in the ADRENAL GLANDS:
(Singhalese: beri = extreme weakness.) Formerly this is why these drugs are sometimes described
a major health problem in many Asian coun- as beta-adrenergic-blocking agents.)
tries, beriberi is a nutritional deficiency disease They work by blocking the stimulation of
resulting from prolonged deficiency of the beta adrenergic receptors by the neuro-
water-soluble vitamin, THIAMINE (vitamin B1). transmitters adrenaline and noradrenaline,
It is often associated with deficiencies of other which are produced at the nerve endings of
members of the the vitamin B complex (see that part of the SYMPATHETIC NERVOUS SYS-
APPENDIX 5: VITAMINS). A major public-health TEM the autonomous (involuntary) network
problem in countries where highly polished rice which facilitates the bodys reaction to anx-
constitutes the staple diet, beriberi also occurs iety, stress and exercise the fear and flight
sporadically in alcoholics (see WERNICKES response.
ENCEPHALOPATHY) and in people suffering Beta1 blockers reduce the frequency and
from chronic malabsorptive states. Clinical force of the heartbeat; beta2 blockers prevent
symptoms include weakness, paralysis involv- vasodilation (increase in the diameter of blood
ing especially the hands and feet (associated vessels), thus influencing the patients blood
with sensory loss, particularly in the legs) and pressure. Beta1 blockers also affect blood pres-
burning sensations in the feet (dry beriberi). sure, but the mechanism of their action is
Alternatively, it is accompanied by oedema, unclear. They can reduce to normal an
palpitations and a dilated heart (wet beriberi). abnormally fast heart rate so the power of the
Death usually results from cardiac failure. heart can be concomitantly controlled: this
Thiamine deficiency can be confirmed by esti- reduces the oxygen requirements of the heart
mating erythrocyte transketolase concentration; with an advantageous knock-on effect on the
blood and urine thiamine levels can be meas- respiratory system. These are valuable thera-
ured by high-pressure liquid chromatography. peutic effects in patients with ANGINA or who
 Bilateral 77

have had a myocardial infarction (heart attack estimation of the true value. For example, if a
see HEART, DISEASES OF), or who suffer from researcher is studying the effects of two differ-
HYPERTENSION. Beta2 blockers reduce tremors ent drugs on the same disease and personally
in muscles elsewhere in the body which are a favours one, unless they have been blinded to B
feature of anxiety or the result of thyrotoxicosis which patient is receiving which treatment,
(an overactive thyroid gland see under they may unwittingly cause bias in the results
THYROID GLAND, DISEASES OF). Non- by regarding those treated with their preferred
cardioselective blockers also reduce the drug as being healthier.
abnormal pressure caused by the increase in
the fluid in the eyeball that characterises Bicarbonate of Soda
GLAUCOMA. Also known as baking soda. Bicarbonate of soda
Many beta-blocking drugs are now available; is an alkali, sometimes used as a home remedy
minor therapeutic differences between them for indigestion or for soothing insect bites.
may influence the choice of a drug for a particu-
lar patient. Among the common drugs are: Biceps
A term used for a muscle that has two heads.
Primarily cardioselective Non-cardioselective The biceps femoris flexes the knee and
Acebutolol Labetalol extends the hip, and the biceps brachii supin-
Atenolol Nadolol ates the forearm and flexes the elbow and
Betaxolol Oxprenolol shoulder.
Celiprolol Propanolol
Metoprolol Timolol
Bicuspid
These powerful drugs have various side- Having two cusps. The premolars are bicuspid
effects and should be prescribed and monitored teeth, and the mitral valve of the HEART is a
with care. In particular, people who suffer from bicuspid valve.
asthma, bronchitis or other respiratory prob-
lems may develop breathing difficulties. Long- Bifid
term treatment with beta blockers should not Split into two parts.
be suddenly stopped, as this may precipitate a
severe recurrence of the patients symptoms Bifocal Lens
including, possibly, a sharp rise in blood pres- A spectacle lens in which the upper part is
sure. Gradual withdrawal of medication should shaped to assist distant vision and the lower
mitigate untoward effects. part is for close work such as reading.

Beta Blockers Bifurcation

See BETA-ADRENOCEPTOR-BLOCKING DRUGS. The point at which a structure (for example, a
blood vessel) divides into two branches.
Betamethasone
One of the CORTICOSTEROIDS which has an Biguanides
action comparable to that of PREDNISOLONE, Biguanides are a group of oral drugs, of which
but in much lower dosage. In the form of beta- METFORMIN is the only one available for treat-
methasone valerate it is used as an application ment, used to treat non-insulin-dependent dia-
to the skin as an ointment or cream. betics when strict dieting and treatment with
SULPHONYLUREAS have failed. Metformin acts
Betatron
See RADIOTHERAPY.
mainly by reducing GLUCONEOGENESIS and by
increasing the rate at which the body uses up
Bezoar glucose. Hypoglycaemia is unusual, unless
A mass of ingested foreign material found in the taken in overdose. Gastrointestinal side-effects
stomach, usually in children or people with such as anorexia, nausea, vomiting and transient
psychiatric illnesses. It may cause gastric diarrhoea are common initially and may persist,
obstruction and require surgical removal. The particularly if large doses are taken. Metformin
commonest type consists of hair and is known should not be given to patients with renal fail-
as a trichobezoar. ure, in whom there is a danger of inducing lactic
acidosis. (See also DIABETES MELLITUS.)
Bias
A statistical term describing a systematic influ- Bilateral
ence which leads to consistent over- or under- Occurring on both sides of the body.
 78 Bile

Bile Binaural
A thick, bitter, greenish-brown fluid, secreted Relating to both ears.
by the liver and stored in the gall-bladder (see
B LIVER). Consisting of water, mucus, bile pig- Binocular
ments including BILIRUBIN, and various salts, it Relating to both eyes. Binocular vision involves
is discharged through the bile ducts into the focusing on an object with both eyes simul-
intestine a few centimetres below the stomach. taneously and is important in judging distance.
This discharge is increased shortly after eating,
and again a few hours later. It helps in the Binovular Twins
digestion and absorption of food, particularly Twins who result from the fertilisation of two
fats, and is itself reabsorbed, passing back separate ova. (See MULTIPLE BIRTHS.)
through the blood of the liver. In JAUNDICE,
obstruction of the bile ducts prevents dis- Bio-Availability
charge, leading to a build-up of bile in the Bio-availability refers to the proportion of a
blood and deposition in the tissues. The skin drug reaching the systemic circulation after a
becomes greenish-yellow, while the stools particular route of administration. The most
become grey or white and the urine dark. important factor is first-pass metabolism
Vomiting of bile is a sign of intestinal obstruc- that is, pre-systemic metabolism in either
tion, but may occur in any case of persistent the intestine or the liver. Many lipid-soluble
retching or vomiting, and should be fully drugs such as beta blockers (see BETA-
investigated. ADRENOCEPTOR-BLOCKING DRUGS), some tri-
cyclic ANTIDEPRESSANT DRUGS, and various
Bile Duct opiate ANALGESICS are severely affected. Food
The channel running from the gall-bladder (see may affect bio-availability by modifying gastric
LIVER) to the DUODENUM; carries BILE. emptying, thus slowing drug absorption. In-
gested calcium may combine with drugs such as
tetracyclines, further reducing their absorption.
Bilharziasis
Bilharziasis is another name for Biofeedback
SCHISTOSOMIASIS.
A technique whereby an auditory or visual
stimulus follows on from a physiological
Biliary Colic response. Thus, a subjects ELECTROCARDIO-
Severe pain caused by the attempted (and GRAM (ECG) may be monitored, and a signal
sometimes successful) expulsion of a gall-stone passed back to the subject indicating his or her
from the gall-bladder via the BILE DUCT. The heart rate: for example, a red light if the rate is
pain, which is felt in the upper right corner of between 50 and 60 beats a minute; a green light
the abdomen, may last for an hour or more. if it is between 60 and 70 a minute. Once the
Strong ANALGESICS are required to subdue the subject has learned to discriminate between
pain and the patient may need hospital admis- these two rates, he or she can then learn to con-
sion for examination and eventual surgery. trol the heart rate. How this is learned is not
Attacks may recur, and the pain is sometimes clear, but by utilising biofeedback some subjects
mistakenly diagnosed as signalling a heart can control heart rate and blood pressure, relax
attack. spastic muscles, bring migraine under control
and even help constipation.
Bilirubin
The chief pigment in human BILE. It is derived Biological Warfare
from HAEMOGLOBIN which is the red pigment The use of living organisms or infectious
of the red blood corpuscles. The site of manu- agents derived from them to disable or kill
facture of bilirubin is the RETICULO- men, animals or plants in the pursuit of war.
ENDOTHELIAL SYSTEM. When bile is passed Such warfare, along with chemical warfare, was
into the intestine from the gall-bladder (see condemned in 1925 by the Geneva Conven-
LIVER), part of the bilirubin is converted into tion, and the United Nations has endorsed this
stercobilin and excreted in the FAECES. The policy. Even so, some countries have experi-
remainder is reabsorbed into the bloodstream, mented with possible biological agents, includ-
and of this portion the bulk goes back to the ing those causing ANTHRAX and BOTULISM,
liver to be re-excreted into the bile, whilst a with the intention of delivering them by land,
small proportion is excreted in the urine as sea or water-based missiles. These develop-
urobilinogen. ments have prompted other countries to search
 Birth Canal 79

for ways of annulling the lethal consequences of POX. Particular problems in detecting and hand-
biological warfare. ling attacks are the time lags between exposure
of a population to dangerous agents and the
Biomechanical Engineering onset of victims symptoms, and the fact that B
The joint utilisation of engineering and bio- early symptoms might initially be taken as the
logical knowledge to illuminate normal and result of a naturally occurring disease. Man-
abnormal functions of the human body. Blood agement of any biological attack must depend
flow, the reaction of bones and joints to stress, on systems already in place for managing new
the design of kidney dialysis machines, and the diseases, new epidemics or traditional diseases.
development of artificial body parts are among The effectiveness of public-health surveillance
the practical results of this collaboration. varies widely from country to country, and
even advanced economies may not have the
Biopsy staff and facilities to investigate anything other
Biopsy means the removal and examination of than a recognised epidemic. As attacks might
tissue from the living body for diagnostic pur- well occur without warning, tackling them
poses. For example, a piece of a tumour may be could be a daunting task. Intelligence warn-
cut out and examined to determine whether it ings about proposed attacks might, however,
is cancerous. allow for some preventive and curative meas-
ures to be set up. Medical experts in the US
Bioremediation believe that deployment of existing com-
The use of the natural properties of living munity disaster teams working to pre-prepared
things to remove hazards that threaten human plans, and the development of specially
and animal health. When a pollutant first trained strike teams, should cut the numbers
appears in a local environment, existing micro- of casualties and deaths from a bioterrorist
organisms such as bacteria attempt to make use attack. Nevertheless, bioterrorism is an alarm-
of the potential source of energy and as a side- ing prospect.
effect detoxify the polluting substance. This is
an evolutionary process that normally would Biotin
take years. One of the dozen or so vitamins included in the
Scientists have engineered appropriate genes vitamin B complex. It is found in liver, eggs and
from other organisms into BACTERIA, or some- meat, and also synthesised by bacteria in the
times plants, to accelerate this natural evo- gut. Absorption from the gut is prevented by
lutionary process. For effective digestion of avidin, a constituent of egg-white. The daily
waste, a micro-organism must quickly and requirement is small: a fraction of a milligram
completely digest organic waste without pro- daily. Gross deficiency results in disturbances of
ducing unpleasant smells or noxious gases, be the skin, a smooth tongue and lassitude. (See
non-pathogenic and be able to reproduce in APPENDIX 5: VITAMINS.)
hostile conditions. For example, American
researchers have discovered an anaerobic bac-
terium that neutralises dangerous chlorinated
Bipolar Disorder
A type of mental illness typified by mood
chemical compounds such as trichlorethane,
swings between elation (mania) and depression
which can pollute soil, into a harmless molecule
(see MENTAL ILLNESS).
called ethens. But the bacteria do not thrive in
soil. So the dechlorinating genes in this bac-
terium are transferred to bacteria that are Bird Fanciers Lung
acclimatised to living in toxic areas and can Also known as pigeon breeders lung, this is a
more efficiently carry out the required detoxifi- form of extrinsic allergic ALVEOLITIS resulting
cation. Other research has been aimed at from sensitisation to birds. In bird fanciers, skin
detoxifying the byproducts of DDT, a trouble- tests sometimes show sensitisation to birds
some and resistant pollutant. Bioremediation droppings, eggs, protein and serum, even
should prove to be an environmentally friendly through there has been no evidence of any
and cost-effective alternative to waste inciner- illness.
ation or chemically based processes for washing
contaminated soils. Birth Canal
The passage that extends from the neck of the
Bioterrorism womb (UTERUS), known as the CERVIX UTERI,
Terror attacks on civilian communities using to the opening of the VAGINA. The baby passes
biological agents such as ANTHRAX and SMALL- along this passage during childbirth.
 80 Birth Control

Birth Control established vertebral osteoporosis (see BONE,

See CONTRACEPTION. DISORDERS OF). Their advantage over CALCI-
TONIN (which has to be given by subcutaneous
B Birth Defects or intramuscular injection) is that they can be
See CONGENITAL. taken orally. They act by reducing the increased
rate of bone turnover associated with the dis-
Birth Marks ease. Disodium etidronate is used with calcium
Birth marks are of various kinds; the most carbonate in a 90-day cycle (duration of therapy
common are port-wine marks (see NAEVUS). up to three years) in the treatment of
Pigment spots are found, very often raised osteoporosis.
above the skin surface and more or less hairy,
being then called moles (see MOLE). Bites and Stings
Animal bites are best treated as puncture
Birth Pool wounds and simply washed and dressed. In
A pool of warm water in which a woman can some cases ANTIBIOTICS may be given to min-
give birth to her baby. The infant is delivered imise the risk of infection, together with TET-
into the water. The method was introduced ANUS toxoid if appropriate. Should RABIES be a
during the 1980s and is claimed to make deliv- possibility, then further treatment must be con-
ery less painful and upsetting. sidered. Bites and stings of venomous reptiles,
amphibians, scorpions, snakes, spiders, insects
Birth Rate and fish may result in clinical effects character-
In 2003, 695,500 live births were registered in istic of that particular poisoning. In some cases
the United Kingdom; 38 per cent occurred out- specific ANTIVENOM may be administered to
side marriage. Overall, total fertility is falling reduce morbidity and mortality.
slowly. The number of births per 1,000 women Many snakes are non-venomous (e.g.
aged over 40 years has been rising, and in 1999 pythons, garter snakes, king snakes, boa con-
was 8.9 per cent. In Great Britain in 2003, strictors) but may still inflict painful bites and
193,817 legal abortions were performed under cause local swelling. Most venomous snakes
the Abortion Act 1967. belong to the viper and cobra families and are
common in Asia, Africa, Australia and South
Bisacodyl America. Victims of bites may experience vari-
Bisacodyl is a laxative which acts by stimulation
of the nerve endings in the colon by direct con- ous effects including swelling, PARALYSIS of the
tact with the mucous lining. bitten area, blood-clotting defects, PALPITA-
TION, respiratory difficulty, CONVULSIONS and
Bisexual other neurotoxic and cardiac effects. Victims
Having the qualities of both sexes. The term is should be treated as for SHOCK that is, kept at
used to describe people who are sexually rest, kept warm, and given oxygen if required
attracted to both men and women. but nothing by mouth. The bite site should be
immobilised but a TOURNIQUET must not be
Bismuth used. All victims require prompt transfer to a
Various bismuth chelates and complexes, such medical facility. When appropriate and avail-
as sucralfate, effective in healing gastric and able, antivenoms should be administered as
duodenal ulcers are available. They may act by a soon as possible.
direct toxic effect on gastric HELICOBACTER Similar management is appropriate for bites
PYLORI, or by stimulating mucosal prosta- and stings by spiders, scorpions, sea-snakes,
glandin (see PROSTAGLANDINS) or bicarbonate venomous fish and other marine animals and
secretion. Healing tends to be longer than insects.
with H2-RECEPTOR ANTAGONISTS and relapse
still occurs. New regimens are being developed Bites and stings in the UK The adder
involving co-administration with antibiotics. (Vipera berus) is the only venomous snake
ENCEPHALOPATHY, described with older high- native to Britain; it is a timid animal that bites
dose bismuth preparations, has not been only when provoked. Fatal cases are rare, with
reported. only 14 deaths recorded in the UK since 1876,
the last of these in 1975. Adder bites may result
Bisphosphonates in marked swelling, weakness, collapse, shock,
Bisphosphonates, of which disodium etidronate and in severe cases HYPOTENSION, non-specific
is one, are a group of drugs used mainly in the changes in the electrocardiogram and per-
treatment of PAGETS DISEASE OF BONE and in ipheral leucocytosis. Victims of adder bites
 Blenorrhoea 81

should be transferred to hospital even if asymp- used for prevention of this infection (it is
tomatic, with the affected limb being immobil- reserved for treatment), blackwater fever has
ised and the bite site left alone. Local incisions, become very unusual. Treatment is as for severe
suction, tourniquets, ice packs or permangan- complicated P. falciparum infection with renal B
ate must not be used. Hospital management impairment; dialysis and blood transfusion are
may include use of a specific antivenom, usually indicated. When inadequately treated,
Zagreb. the mortality rate may be over 40 per cent but,
The weever fish is found in the coastal waters with satisfactory intensive therapy, this should
of the British Isles, Europe, the eastern Atlantic, be reduced substantially.
and the Mediterranean Sea. It possesses venom-
ous spines in its dorsal fin. Stings and enveno- Bladder, Diseases of
mation commonly occur when an individual See URINARY BLADDER, DISEASES OF and GALL-
treads on the fish. The victim may experience a BLADDER, DISEASES OF; see also URINE.
localised but increasing pain over two hours. As
the venom is heat-labile, immersion of the
affected area in water at approximately 40 C or Bladders
as hot as can be tolerated for 30 minutes should Sacs formed of muscular and fibrous tissue and
ease the pain. Cold applications will worsen the lined by a mucous membrane, which is united
discomfort. Simple ANALGESICS and ANTIHIS- loosely to the muscular coat so as freely to allow
TAMINE DRUGS may be given.
increase and decrease in the contained cavity.
Bees, wasps and hornets are insects of the Bladders are designed to contain some secretion
order Hymenoptera and the females possess or excretion, and communicate with the exter-
stinging apparatus at the end of the abdomen. ior by a narrow opening through which their
Stings may cause local pain and swelling but contents can be discharged. In humans there
rarely cause severe toxicity. Anaphylactic (see are two: the gall-bladder and the urinary
ANAPHYLAXIS) reactions can occur in sensitive
bladder.
individuals; these may be fatal. Deaths caused
by upper-airway blockage as a result of stings in Gall-bladder This is situated under the liver
the mouth or neck regions are reported. In vic- in the upper part of the abdomen, and its func-
tims of stings, the stinger should be removed as tion is to store the BILE, which it discharges into
quickly as possible by flicking, scraping or pull- the intestine by the BILE DUCT. For further
ing. The site should be cleaned. Antihistamines details, see LIVER.
and cold applications may bring relief. For
anaphylactic reactions ADRENALINE, by intra- Urinary bladder This is situated in the
muscular injection, may be required. pelvis, in front of the last part of the bowel. In
the full state, the bladder rises up into the
Black Death abdomen and holds about 570 ml (a pint) of
An old name for PLAGUE. urine. Two fine tubes, called the ureters, lead
into the bladder, one from each kidney; and the
Blackheads urethra, a tube as wide as a lead pencil when
See ACNE. distended, leads from it to the exterior a dis-
tance of 4 cm (1 inches) in the female and 20
Blackwater Fever cm (8 inches) in the male. The exit from the
This is caused by rapid breakdown of red blood bladder to the urethra is kept closed by a mus-
cells (acute intravascular haemolysis), with cular ring which is relaxed every time urine is
resulting kidney failure as the breakdown passed.
products block the vessels serving the kidney
filtration units (see KIDNEYS). It is associated
with severe Plasmodium falciparum infection. Bleeding
The complication is frequently fatal, being See HAEMORRHAGE; VENESECTION.
associated with HAEMOGLOBINURIA, JAUNDICE,
fever, vomiting and severe ANAEMIA. In an Blenorrhoea
extreme case the patients urine appears black. An excessive discharge of mucus or slimy
Tender enlarged liver and spleen are usually material from a surface, such as that of the eye,
present. The disease is triggered by quinine nose, bowel, etc. The word catarrh is used
usage at subtherapeutic dosage in the presence with the same meaning, but also includes the
of P. falciparum infection, especially in the non- idea of inflammation as the cause of such
immune individual. Now that quinine is rarely discharge.
 82 Bleomycin

Bleomycin obtain help and advice from the Royal National

A CYTOTOXIC antibiotic, obtained from Strep- Institute for the Blind (www.rnib.org.uk).
tomyces verticillus, used to treat solid cancerous
B tumours of the upper part of the gut and genital Night blindness An inability to see in the
tract, and lymphomas. Like other cytotoxic dark. It can be associated with retinitis pigmen-
drugs it can have serious side-effects, and bleo- tosa or vitamin A deficiency (see EYE, DIS-
mycin may cause pulmonary fibrosis and skin ORDERS OF).
pigmentation.
Blood
Blepharitis Blood consists of cellular components sus-
Inflammation of the eyelids. (See EYE, DIS- pended in plasma. It circulates through the
ORDERS OF.) blood vessels, carrying oxygen and nutrients to
the organs and removing carbon dioxide and
Blepharospasm other waste products for excretion. In addition,
See EYE, DISORDERS OF. it is the vehicle by which hormones and other
humoral transmitters reach their sites of action.
Blind Loop Syndrome
A disorder in which abnormal FAECES occur as a Composition The cellular components are
result of a redundant loop in the small INTES- red cells or corpuscles (ERYTHROCYTES), white
TINE. The loop obstructs the normal flow of the cells (LEUCOCYTES and lymphocytes see
contents of the bowel, causing stagnation. The LYMPHOCYTE), and platelets.
syndrome is characterised by light-yellow, The red cells are biconcave discs with a
smelly, fatty, bulky faeces. The patient suffers diameter of 7.5m. They contain haemoglobin
from tiredness, malaise and loss of weight. Pre- an iron-containing porphyrin compound,
vious abdominal surgery is sometimes the which takes up oxygen in the lungs and releases
cause, but the condition can be inherited. it to the tissue.
Blockage of intestinal contents upsets the The white cells are of various types, named
bowels normal bacterial balance and hinders according to their appearance. They can leave
the normal absorption of nutrients. Treatment the circulation to wander through the tissues.
is either with antibiotics or, if that fails, surgery. They are involved in combating infection,
wound healing, and rejection of foreign bodies.
Blindness Pus consists of the bodies of dead white cells.
The statutory definition for the purposes of Platelets are the smallest cellular components
registration as a blind person under the and play an important role in blood clotting (see
National Assistance Act 1948 is that the per- COAGULATION).
son is so blind as to be unable to perform any Erythrocytes are produced by the bone mar-
work for which eyesight is essential. Generally row in adults and have a life span of about 120
this is vision worse than 6/60 in the better eye, days. White cells are produced by the bone
or with better acuity than this but where the
field of vision is markedly contracted in the
greater part of its extent. Partial sight has no
statutory definition, but there are official guide-
lines for registering a person as partially sighted:
generally these are a corrected visual acuity of 3/
60 or less in the better eye with some contrac-
tion of the peripheral field, or better with
gross field defects. In the UK more than
100,000 people are registered as legally blind
and some 50,000 as partially sighted. The
World Health Organisation has estimated that
there are over 40 million binocularly blind
people in the world. The causes of blindness
vary with age and degree of development of
the country. In western society the commonest
causes are glaucoma, diabetic retinopathy,
other retinal diseases and senile cataract. (See
also VISION.)
Red and white blood cells and platelets.
Any blind person, or his or her relatives, can
 Blood Groups 83

marrow and lymphoid tissue. Plasma consists of required to return a unit volume of the blood to
water, ELECTROLYTES and plasma proteins; it normal pH). These values are vital in monitor-
comprises 4858 per cent of blood volume. ing the severity of illness in patients receiving
Plasma proteins are produced mainly by the intensive care or who have severe respiratory B
liver and by certain types of white cells. Blood illness, as they provide a guide to the effective-
volume and electrolyte composition are closely ness of oxygen transport between the outside air
regulated by complex mechanisms involving and the body tissues. Thus they are both a
the KIDNEYS, ADRENAL GLANDS and guide to whether the patient is being optimally
HYPOTHALAMUS. ventilated, and also a general guide to the
severity of their illness.
Blood Bank
A department in which blood products are pre- Blood Groups
pared, stored, and tested prior to transfusion People are divided into four main groups in
into patients. respect of a certain reaction of the blood. This
depends upon the capacity of the serum of one
Blood Brain Barrier persons blood to cause the red cells of anothers
A functional, semi-permeable membrane separ- to stick together (agglutinate). The reaction
ating the brain and cerebrospinal fluid from the depends on antigens (see ANTIGEN), known as
blood. It allows small and lipid-soluble mol- agglutinogens, in the erythrocytes and on
ecules to pass freely but is impermeable to large ANTIBODIES, known as agglutinins, in the
or ionised molecules and cells. serum. There are two of each, the agglutinogens
being known as A and B. A persons erythro-
Blood Clot cytes may have (1) no agglutinogens, (2)
agglutinogen A, (3) agglutinogen B, (4)
A blood clot arises when blood comes into con-
agglutinogens A and B: these are the four
tact with a foreign surface for example, dam-
groups. Since the identification of the ABO and
aged blood vessels or when tissue factors are
Rhesus factors (see below), around 400 other
released from damaged tissue. An initial plug
antigens have been discovered, but they cause
of PLATELETS is converted to a definitive clot
few problems over transfusions.
by the deposition of FIBRIN, which is formed
In blood transfusion, the person giving and
by the clotting cascade and erythrocytes. (See
the person receiving the blood must belong to
COAGULATION.)
the same blood group, or a dangerous reaction
will take place from the agglutination that
Blood Corpuscle occurs when blood of a different group is pres-
See ERYTHROCYTES and LEUCOCYTES.
ent. One exception is that group O Rhesus-
negative blood can be used in an emergency for
Blood Count anybody.
The number of each of the cellular components
per litre of blood. It may be calculated using a Agglutinogens Agglutinins Frequency
microscope or by an automated process. in the in the in Great
Group erythrocytes plasma Britain
Blood, Diseases of AB A and B None 2 per cent
See ANAEMIA; LEUKAEMIA; LYMPHOMA; MYELO-
A A Anti-B 46 per cent
B B Anti-A 8 per cent
MATOSIS; THROMBOSIS.
O Neither Anti-A and 44 per cent
A nor B Anti-B
Blood Donor
An individual who donates his or her own Rhesus factor In addition to the A and B
blood for use in patients of compatible blood agglutinogens (or antigens), there is another
group who require transfusion. one known as the Rhesus (or Rh) factor so
named because there is a similar antigen in the
Blood Gases red blood corpuscles of the Rhesus monkey.
Specifically, this describes the measurement of About 84 per cent of the population have this
the tensions of oxygen and carbon dioxide in Rh factor in their blood and are therefore
blood. However, it is commonly used to known as Rh-positive. The remaining 16 per
describe the analysis of a sample of heparinised cent who do not possess the factor are known as
arterial blood for measurement of oxygen, car- Rh-negative.
bon dioxide, oxygen saturation, pH, bicarbon- The practical importance of the Rh factor is
ate, and base excess (the amount of acid that, unlike the A and B agglutinogens, there
 84 Blood-Letting

are no naturally occurring Rh antibodies. How- accompanied by arterial disease (see ARTERIES,
ever, such antibodies may develop in a Rh- DISEASES OF) with an increased risk of STROKE,
negative person if the Rh antigen is introduced heart attack and heart failure (see HEART,
B into his or her circulation. This can occur (a) if DISEASES OF). Various ANTIHYPERTENSIVE
a Rh-negative person is given a transfusion of DRUGS are available; these should be carefully
Rh-positive blood, and (b) if a Rh-negative evaluated, considering the patients full clinical
mother married to a Rh-positive husband history, before use.
becomes pregnant and the fetus is Rh-positive. HYPOTENSION may result from superficial
If the latter happens, the mother develops Rh vasodilation (for example, after a bath, in fevers
antibodies which can pass into the fetal circula- or as a side-effect of medication, particularly
tion, where they react with the babys Rh anti- that prescribed for high blood pressure) and
gen and cause HAEMOLYTIC DISEASE of the fetus occur in weakening diseases or heart failure.
and newborn. This means that, untreated, the The blood pressure generally falls on standing,
child may be stillborn or become jaundiced leading to temporary postural hypotension a
shortly after birth. particular danger in elderly people.
As about one in six expectant mothers is Rh-
negative, a blood-group examination is now Blood Test
considered an essential part of the antenatal Removal of venous, capillary or arterial blood
examination of a pregnant woman. All such for haematological, microbiological or bio-
Rh-negative expectant mothers are now given a chemical laboratory investigations.
Rhesus card showing that they belong to the
rhesus-negative blood group. This card should Blood Transfusion
always be carried with them. Rh-positive blood See TRANSFUSION Transfusion of blood.
should never be transfused to a Rh-negative girl
or woman. Blood Vessel
Tube through which blood is conducted from
Blood-Letting or to the heart. Blood from the heart is con-
See VENESECTION. ducted via arteries and arterioles through capil-
laries and back to the heart via venules and then
Blood-Poisoning veins. (See ARTERIES and VEINS.)
See SEPTICAEMIA.
BMA
Blood Pressure See BRITISH MEDICAL ASSOCIATION (BMA).
Blood pressure is that pressure which must be
applied to an artery in order to stop the pulse BMI
beyond the point of pressure. It may be roughly See BODY MASS INDEX.
estimated by feeling the pulse at the wrist, or
accurately measured using a SPHYGMO- Body Mass Index
MANOMETER. It is dependent on the pumping Body Mass Index (BMI) provides objective cri-
force of the heart, together with the volume of teria of size to enable an estimation to be made
blood, and on the elasticity of the blood vessels. of an individuals level or risk of morbidity and
The blood pressure is biphasic, being greatest mortality. The BMI, which is derived from the
(systolic pressure) at each heartbeat and falling extensive data held by life-insurance companies,
(diastolic pressure) between beats. The average is calculated by dividing a persons weight by
systolic pressure is around 100 mm Hg in chil- the square of his or her height (kilograms/
dren and 120 mm Hg in young adults, gener- metres2). Acceptable BMIs range from 20 to 25
ally rising with age as the arteries get thicker and any figure above 30 characterises obesity.
and harder. Diastolic pressure in a healthy The Index may be used (with some modifica-
young adult is about 80 mm Hg, and a rise in tion) to assess children and adolescents. (See
diastolic pressure is often a surer indicator of OBESITY.)
HYPERTENSION than is a rise in systolic pres-
sure; the latter is more sensitive to changes of Boils (Furunculosis)
body position and emotional mood. Hyperten- A skin infection caused by Staphylococcus
sion has various causes, the most important of aureus, beginning in adjacent hair follicles (see
which are kidney disease (see KIDNEYS, DISEASES FOLLICLE). As the folliculitis becomes conflu-
OF), genetic predisposition and, to some extent, ent, a tender red lump develops which becomes
mental stress. Systolic pressure may well be over necrotic (see NECROSIS) centrally with pus for-
200 mm Hg. Abnormal hypertension is often mation. A cluster of boils becoming confluent is
 Bone 85

called a carbuncle. Release of the pus and an whole interior, enclosing marrow in its meshes.
oral antibiotic lead to rapid healing. The marrow of the smaller bones is of great
Recurrent boils are usually due to a reservoir importance. It is red in colour, and in it red
of staphylococcal bacteria (see STAPHYLOCOC- blood corpuscles are formed. Even the densest B
CUS) in a nostril or elsewhere, so an intranasal bone is tunnelled by fine canals (Haversian
antibiotic cream may be prescribed. Under- canals) in which run small blood vessels, nerves
lying DIABETES MELLITUS should always be and lymphatics, for the maintenance and repair
excluded. of the bone. Around these Haversian canals the
bone is arranged in circular plates called lamel-
Bolam Test lae, the lamellae being separated from one
A medico-legal defence for a clinician accused another by clefts, known as lacunae, in which
of failing to provide an acceptable standard of single bone-cells are contained. Even the lamel-
care for one of his or her qualification and lae are pierced by fine tubes known as canaliculi
experience. The defence is that a responsible lodging processes of these cells. Each lamella is
body of medical practitioners would have taken composed of very fine interlacing fibres.
the same action, even though others would have
acted differently. The precise size of a respon- GROWTH OF BONES Bones grow in thickness
sible body has not been defined. The test has from the fibrous tissue and lime salts laid down
been modified following a case referred to as by cells in their substance. The long bones grow
Bolitho, in which it was held that the Bolam in length from a plate of cartilage (epiphyseal
defence failed if it could be shown that the cartilage) which runs across the bone about 15
actions relied upon, although shown to be car- cm or more from its ends, and which on one
ried out by some responsible doctors, were surface is also constantly forming bone until the
nonetheless illogical. bone ceases to lengthen at about the age of 16
or 18. Epiphyseal injury in children may lead to
Bolus diminished growth of the limb.
A lump of food prepared for swallowing by
chewing and mixing with saliva. The term is REPAIR OF BONE is effected by cells of micro-
also used to describe the rapid intravenous scopic size, some called osteoblasts, elaborating
injection of fluid or a drug, as opposed to a the materials brought by the blood and laying
slower infusion. down strands of fibrous tissue, between which
Bonding bone earth is later deposited; while other cells,
The formation of a close, selective attachment known as osteoclasts, dissolve and break up
between two individuals, as in the relationship dead or damaged bone. When a fracture has
between a mother and her baby. occurred, and the broken ends have been
brought into contact, these are surrounded by a
Bone mass of blood at first; this is partly absorbed
The framework upon which the rest of the and partly organised by these cells, first into
body is built up. The bones are generally called fibrous tissue and later into bone. The mass sur-
the skeleton, though this term also includes the rounding the fractured ends is called the callus,
cartilages which join the ribs to the breastbone, and for some months it forms a distinct thick-
protect the larynx, etc. ening which is gradually smoothed away, leav-
ing the bone as before the fracture. If the ends
Structure of bone Bone is composed have not been brought accurately into contact,
partly of fibrous tissue, partly of bone matrix a permanent thickening results.
comprising phosphate and carbonate of lime,
intimately mixed together. The bones of a child VARIETIES OF BONES Apart from the structural
are about two-thirds fibrous tissue, whilst those varieties, bones fall into four classes: (a) long
of the aged contain one-third; the toughness of bones like those of the limbs; (b) short bones
the former and the brittleness of the latter are composed of cancellous tissue, like those of the
therefore evident. wrist and the ankle; (c) flat bones like those of
The shafts of the limb bones are composed of the skull; (d) irregular bones like those of the
dense bone, the bone being a hard tube sur- face or the vertebrae of the spinal column
rounded by a membrane (the periosteum) and (backbone).
enclosing a fatty substance (the BONE MAR-
ROW); and of cancellous bone, which forms the The skeleton consists of more than 200
short bones and the ends of long bones, in bones. It is divided into an axial part, compris-
which a fine lace-work of bone fills up the ing the skull, the vertebral column, the ribs
 86 Bone, Disorders of

with their cartilages, and the breastbone; and an by joints. In the shoulder lie the clavicle or
appendicular portion comprising the four collar-bone (which is immediately beneath the
limbs. The hyoid bone in the neck, together skin, and forms a prominent object on the front
B with the cartilages protecting the larynx and of the neck), and the scapula or shoulder-blade
windpipe, may be described as the visceral behind the chest. In the upper arm is a single
skeleton. bone, the humerus. In the forearm are two
bones, the radius and ulna; the radius, in the
AXIAL SKELETON The skull consists of the cra- movements of alternately turning the hand
nium, which has eight bones, viz. occipital, two palm up and back up (called supination and
parietal, two temporal, one frontal, ethmoid, pronation respectively), rotating around the
and sphenoid; and of the face, which has 14 ulna, which remains fixed. In the carpus or
bones, viz. two maxillae or upper jaw-bones, wrist are eight small bones: the scaphoid, lun-
one mandible or lower jaw-bone, two malar or ate, triquetral, pisiform, trapezium, trapezoid,
cheek bones, two nasal, two lacrimal, two tur- capitate and hamate. In the hand proper are five
binal, two palate bones, and one vomer bone. bones called metacarpals, upon which are set
(For further details, see SKULL.) The vertebral the four fingers, each containing the three
column consists of seven vertebrae in the cer- bones known as phalanges, and the thumb with
vical or neck region, 12 dorsal vertebrae, five two phalanges.
vertebrae in the lumbar or loin region, the sac- The lower limb consists similarly of the
rum or sacral bone (a mass formed of five ver- region of the hip-bone and three segments the
tebrae fused together and forming the back part thigh, the leg and the foot. The hip-bone is a
of the pelvis, which is closed at the sides by the large flat bone made up of three the ilium, the
haunch-bones), and finally the coccyx (four ischium and the pubis fused together, and
small vertebrae representing the tail of lower forms the side of the pelvis or basin which
animals). The vertebral column has four curves: encloses some of the abdominal organs. The
the first forwards in the neck, the second back- thigh contains the femur, and the leg contains
wards in the dorsal region, the third forwards in two bones the tibia and fibula. In the tarsus
the loins, and the lowest, involving the sacrum are seven bones: the talus (which forms part of
and coccyx, backwards. These are associated the ankle joint); the calcaneus or heel-bone;
with the erect attitude, develop after a child the navicular; the lateral, intermediate and
learns to walk, and have the effect of diminish- medial cuneiforms; and the cuboid. These
ing jars and shocks before these reach internal bones are so shaped as to form a distinct arch
organs. This is aided still further by discs of in the foot both from before back and from
cartilage placed between each pair of vertebrae. side to side. Finally, as in the hand, there are
Each vertebra has a solid part, the body in five metatarsals and 14 phalanges, of which
front, and behind this a ring of bone, the series the great toe has two, the other toes three
of rings one above another forming a bony each.
canal up which runs the spinal cord to pass Besides these named bones there are others
through an opening in the skull at the upper sometimes found in sinews, called sesamoid
end of the canal and there join the brain. (For bones, while the numbers of the regular bones
further details, see SPINAL COLUMN.) The ribs may be increased by extra ribs or diminished by
12 in number, on each side are attached the fusion together of two or more bones.
behind to the 12 dorsal vertebrae, while in front
they end a few inches away from the breast- Bone, Disorders of
bone, but are continued forwards by cartilages. Bone is not an inert scaffolding for the human
Of these the upper seven reach the breastbone, body. It is a living, dynamic organ, being con-
these ribs being called true ribs; the next three tinuously remodelled in response to external
are joined each to the cartilage above it, while mechanical and chemical influences and acting
the last two have their ends free and are called as a large reservoir for calcium and phosphate.
floating ribs. The breastbone, or sternum, is It is as susceptible to disease as any other organ,
shaped something like a short sword, about 15 but responds in a way rather different from the
cm (6 inches) long, and rather over 25 cm (1 rest of the body.
inch) wide.
Bone fractures These occur when there is a
APPENDICULAR SKELETON The upper limb break in the continuity of the bone. This hap-
consists of the shoulder region and three seg- pens either as a result of violence or because the
ments the upper arm, the forearm, and the bone is unhealthy and unable to withstand
wrist with the hand, separated from each other normal stresses.
 Bone, Disorders of 87

by osteoporosis (see below) in post-menopausal

women. Such fractures are typically crush frac-
tures of the vertebrae, fractures of the neck of
the femur, and COLLES FRACTURE (of the B
wrist). Pathological fractures also occur in bone
which has secondary-tumour deposits.
GREENSTICK FRACTURES These occur in young
children whose bones are soft and bend, rather
than break, in response to stress. The bone
tends to buckle on the side opposite to the
force. Greenstick fractures heal quickly but still
need any deformity corrected and plaster of
Paris to maintain the correction.
COMPLICATED FRACTURES These involve dam-
age to important soft tissue such as nerves,
blood vessels or internal organs. In these cases
the soft-tissue damage needs as much attention
as the fracture site.
COMMINUTED FRACTURES A fracture with
more than two fragments. It usually means
that the injury was more violent and that
Examples of fractures: the fibula (thin bone) has a
there is more risk of damage to vessels and
simple fracture of its shaft and a comminuted frac-
ture at its lower end; the tibia has a compound
nerves. These fractures are unstable and take
fracture of its shaft.
longer to unite. Rehabilitation tends to be
protracted.
DEPRESSED FRACTURES Most commonly found
SIMPLE FRACTURES Fractures where the skin in skull fractures. A fragment of bone is forced
remains intact or merely grazed. inwards so that it lies lower than the level of the
COMPOUND FRACTURES have at least one bone surrounding it. It may damage the brain
wound which is in communication with the beneath it.
fracture, meaning that bacteria can enter the
fracture site and cause infection. A compound
fracture is also more serious than a simple frac-
ture because there is greater potential for blood
loss. Compound fractures usually need hospital
admission, antibiotics and careful reduction of
the fracture. Debridement (cleaning and excis-
ing dead tissue) in a sterile theatre may also be
necessary.
The type of fracture depends on the force
which has caused it. Direct violence occurs
when an object hits the bone, often causing a
transverse break which means the break runs
horizontally across the bone. Indirect violence
occurs when a twisting injury to the ankle, for
example, breaks the calf-bone (the tibia) higher
up. The break may be more oblique. A fall on
the outstretched hand may cause a break at the
Depressed fracture of the skull (sagittal view).
wrist, in the humerus or at the collar-bone
depending on the force of impact and age of the
HAIR-LINE FRACTURES These occur when the
person.
bone is broken but the force has not been severe
FATIGUE FRACTURES These occur after the bone
enough to cause visible displacement. These
has been under recurrent stress. A typical
fractures may be easily missed.
example is the march fracture of the second toe,
from which army recruits suffer after long Symptoms and signs The fracture site is
marches. usually painful, swollen and deformed. There is
PATHOLOGICAL FRACTURES These occur in asymmetry of contour between limbs. The limb
bone which is already diseased for example, is held uselessly. If the fracture is in the upper
 88 Bone, Disorders of

limb, the arm is usually supported by the

patient; if it is in the lower limb then the
patient is not able to bear weight on it. The
B limb may appear short because of muscle
spasm.
Examination may reveal crepitus a bony
grating at the fracture site. The diagnosis is
confirmed by radiography.
Treatment Healing of fractures (union)
begins with the bruise around the fracture being
resorbed and new bone-producing cells and
blood vessels migrating into the area. Within a
couple of days they form a bridge of primitive
bone across the fracture. This is called callus.
The callus is replaced by woven bone which
gradually matures as the new bone remodels
itself. Treatment of fractures is designed to
ensure that this process occurs with minimal
residual deformity to the bone involved.
Treatment is initially to relieve pain and may
involve temporary splinting of the fracture site.
Reducing the fracture means restoring the Injury to the spine: compression fracture of 1st
bones to their normal position; this is particu- lumbar vertebra with no damage to spinal cord.
larly important at the site of joints where any
small displacement may limit movement
considerably.

Injury to the spine: fracture/dislocation of 12th

thoracic vertebra with damage to spinal cord.

Reduction may be done under a general

anaesthetic which relaxes muscles and makes
manipulation easier. Traction, which means
sustained but controlled pulling on the bone,
then restores the fragments of the fracture into
their normal position: these are kept in position
with plaster of Paris. If closed traction does not
Impacted fracture of neck of left femur. work, then open reduction of the fracture may
 Bone, Disorders of 89

be needed. This may involve fixing the fracture the spine is fractured, the more serious the con-
with internal-fixation methods, using metal sequences. The injured person should not be
plates, wires or screws to hold the fracture site moved until skilled assistance is at hand; or, if
in a rigid position with the two ends closely he or she must be removed, this should be done B
opposed. This allows early mobilisation after on a rigid shutter or door, not on a canvas
fractures and speeds return to normal use. stretcher or rug, and there should be no lifting
External fixators are usually metal devices which necessitates bending of the back. In such
applied to the outside of the limb to support an injury an operation designed to remove a
the fracture site. They are useful in compound displaced piece of bone and free the spinal cord
fractures where internal fixators are at risk of from pressure is often necessary and successful
becoming infected. in relieving the paralysis. DISLOCATIONS or SUB-
Consolidation of a fracture means that repair LUXATION of the spine are not uncommon in
is complete. The time taken for this depends certain sports, particularly rugby. Anyone who
on the age of the patient, the bone and the type has had such an injury in the cervical spine (i.e.
of fracture. A wrist fracture may take six weeks, in the neck) should be strongly advised not to
a femoral fracture three to six months in an return to any form of body-contact or vehicular
adult. sport.
Complications of fractures are fairly com- Simple fissured fractures and depressed frac-
mon. In non-union, the fracture does not unite tures of the skull often follow blows or falls on
usually because there has been too much the head, and may not be serious, though there
mobility around the fracture site. Treatment is always a risk of damage which is potentially
may involve internal fixation (see above). Mal- serious to the brain at the same time.
union means that the bone has healed with a Compound fractures may result in infection
persistent deformity and the adjacent joint within the skull, and if the skull is extensively
may then develop early osteoarthritis. broken and depressed, surgery is usually
Myositis ossificans may occur at the elbow required to check any intercranial bleeding or
after a fracture. A big mass of calcified material to relieve pressure on the brain.
develops around the fracture site which restricts The lower jaw is often fractured by a blow on
elbow movements. Late surgical removal (after the face. There is generally bleeding from the
612 months) is recommended. mouth, the gum being torn. Also there are pain
Fractured neck of FEMUR typically affects and grating sensations on chewing, and
elderly women after a trivial injury. The bone is unevenness in the line of the teeth. The treat-
usually osteoporotic. The leg appears short and ment is simple, the line of teeth in the upper
is rotated outwards. Usually the patient is jaw forming a splint against which the lower
unable to put any weight on the affected leg and jaw is bound, with the mouth closed.
is in extreme pain. The fractures are classified
according to where they occur: Congenital diseases These are rare but
subcapital where the neck joins the head of
the femur.
may produce certain types of dwarfism or a sus-
ceptibility to fractures (osteogenesis
intertrochanteric through the trochanter. imperfecta).
subtrochanteric transversely through the
Infection of bone (osteomyelitis) may
upper end of the femur (rare).
Most of these fractures of the neck of femur occur after an open fracture, or in newborn
need fixing by metal plates or hip replacements, babies with SEPTICAEMIA. Once established it is
as immobility in this age group has a mortality very difficult to eradicate. The bacteria appear
of nearly 100 per cent. Fractures of the femur capable of lying dormant in the bone and are
shaft are usually the result of severe trauma such not easily destroyed with antibiotics so that
as a road accident. Treatment may be conserva- prolonged treatment is required, as might be
tive or operative. surgical drainage, exploration or removal of
In fractures of the SPINAL COLUMN, mere dead bone. The infection may become chronic
damage to the bone as in the case of the so- or recur.
called compression fracture, in which there is
no damage to the spinal cord is not necessarily Osteomalacia (rickets) is the loss of min-
serious. If, however, the spinal cord is damaged, eralisation of the bone rather than simple loss of
as in the so-called fracture dislocation, the acci- bone mass. It is caused by vitamin D deficiency
dent may be a very serious one, the usual result and is probably the most important bone dis-
being paralysis of the parts of the body below ease in the developing world. In sunlight the
the level of the injury. Therefore the higher up skin can synthesise vitamin D (see APPENDIX 5:
 90 Bone, Disorders of

VITAMINS), but normally rickets is caused by a important implications for preventing and
poor diet, or by a failure to absorb food nor- treating osteoporosis.
mally (malabsorbtion). In rare cases vitamin D
B cannot be converted to its active state due to the Treatment Antiresorptive drugs: hormone
congenital lack of the specific enzymes and the replacement therapy also valuable in treating
rickets will fail to respond to treatment with menopausal symptoms; treatment for at least
vitamin D. Malfunction of the parathyroid five years is necessary, and prolonged use may
gland or of the kidneys can disturb the dynamic increase risk of breast cancer. Cyclical oral
equilibrium of calcium and phosphate in the administration of disodium etidronate one of
body and severely deplete the bone of its stores the bisphosphonate group of drugs with cal-
of both calcium and phosphate. cium carbonate is also used (poor absorption
means the etidronate must be taken on an
Osteoporosis A metabolic bone disease empty stomach). Calcitonin currently avail-
resulting from low bone mass (osteopenia) due able as a subcutaneous injection; a nasal prepar-
to excessive bone resorption. Sufferers are prone ation with better tolerance is being developed.
to bone fractures from relatively minor trauma. Calcium (1,000 mg daily) seems useful in older
With bone densitometry it is now possible to patients, although probably ineffective in peri-
determine individuals risk of osteoporosis and menopausal women, and it is a safe preparation.
monitor their response to treatment. Vitamin D and calcium recent evidence
By the age of 90 one in two women and one suggests value for elderly patients. Anabolic
in six men are likely to sustain an osteoporosis- steroids, though androgenic side-effects (mascu-
related fracture. The incidence of fractures is linisation) make these unacceptable for most
increasing more than would be expected from women.
the ageing of the population, which may reflect With established osteoporosis, the aim of
changing patterns of exercise or diet. treatment is to relieve pain (with analgesics and
Osteoporosis may be classified as primary or physical measures, e.g. lumbar support) and
secondary. Primary consists of type 1 osteo- reduce the risk of further fractures: improve-
porosis, due to accelerated trabecular bone loss, ment of bone mass, the prevention of falls, and
probably as a result of OESTROGENS deficiency. general physiotherapy, encouraging a healthier
This typically leads to crush fractures of ver- lifestyle with more daily exercise.
tebral bodies and fractures of the distal forearm Further information is available from the
in women in their 60s and 70s. Type 2 osteo- National Osteoporosis Society.
porosis, by contrast, results from the slower
age-related cortical and travecular bone loss Pagets disease (see also separate entry) is a
that occurs in both sexes. It typically leads to common disease of bone in the elderly, caused
fractures of the proximal femur in elderly by overactivity of the osteoclasts (cells con-
people. cerned with removal of old bone, before new
Secondary osteoporosis accounts for about bone is laid down by osteoblasts). The bone
20 per cent of cases in women and 40 per cent affected thickens and bows and may become
of cases in men. Subgroups include endocrine painful. Treatment with calcitonin and bisphos-
(thyrotoxicosis see under THYROID GLAND, phonates may slow down the osteoclasts, and so
DISEASES OF, primary HYPERPARATHYROIDISM, hinder the course of the disease, but there is no
CUSHINGS SYNDROME and HYPOGONADISM); cure.
gastrointestinal (malabsorption syndrome, e.g. If bone loses its blood supply (avascular
COELIAC DISEASE, or liver disease, e.g. primary necrosis) it eventually fractures or collapses. If
biliary CIRRHOSIS); rheumatological (RHEUMA- the blood supply does not return, bones
TOID ARTHRITIS or ANKYLOSING SPONDYLITIS); normal capacity for healing is severely
malignancy (multiple MYELOMA or metastatic impaired.
CARCINOMA); and drugs (CORTICOSTEROIDS, For the following diseases see separate art-
HEPARIN). Additional risk factors for icles: RICKETS; ACROMEGALY; OSTEOMALACIA;
osteoporosis include smoking, high alcohol OSTEOGENESIS IMPERFECTA.
intake, physical inactivity, thin body-type and
heredity. Tumours of bone These can be benign
Individuals at risk of osteopenia, or with an (non-cancerous) or malignant (cancerous).
osteoporosis-related fracture, need investigation Primary bone tumours are rare, but secondaries
with spinal radiography and bone densitometry. from carcinoma of the breast, prostate and kid-
A small fall in bone density results in a large neys are relatively common. They may form
increase in the risk of fracture, which has cavities in a bone, weakening it until it breaks
 Botulism 91

under normal load (a pathological fracture). Bone Transplant

The bone eroded away by the tumour may also The insertion of a piece of bone from another
cause problems by causing high levels of cal- site or from another person to fill a defect, pro-
cium in the plasma. vide supporting tissue, or encourage the growth B
of new bone.
EWINGS TUMOUR is a malignant growth affect-
ing long bones, particularly the tibia (calf- Borborygmus
bone). The presenting symptoms are a throb- Flatulence in the bowels (tummy rumbling).
bing pain in the limb and a high temperature.
Treatment is combined surgery, radiotherapy
and chemotherapy. Bornholm Disease
Bornholm disease, also known as devils grip,
MYELOMA is a generalised malignant disease of
and epidemic myalgia, is an acute infective dis-
blood cells which produces tumours in bones ease due to COXSACKIE VIRUSES. It is character-
which have red bone marrow, such as the skull ised by the abrupt onset of pain around the
and trunk bones. These tumours can cause lower margin of the ribs, headache, and fever; it
pathological fractures. occurs in epidemics, usually during warm wea-
ther, and is more common in young people
OSTEOID OSTEOMA is a harmless small growth than in old. The illness usually lasts seven to
which can occur in any bone. Its pain is typic- ten days. It is practically never fatal. The dis-
ally removed by aspirin. ease is named after the island of Bornholm in
the Baltic, where several epidemics have been
OSTEOSARCOMA is a malignant tumour of bone described.
with a peak incidence between the ages of ten
and 20. It typically involves the knees, causing a Botulinum Toxin
warm tender swelling. Removal of the growth The toxin of the anaerobic bacterium
with bone conservation techniques can often CLOSTRIDIUM botulinum is now routinely used
replace amputation as the definitive treatment. to treat focal DYSTONIA in adults. This includes
Chemotherapy can improve long-term survival. blepharospasm (see EYE, DISORDERS OF), SPAS-
MODIC TORTICOLLIS, muscular spasms of the
Bone Graft face, squint and some types of tremor. Injected
See BONE TRANSPLANT. close to where the nerve enters the affected
muscles, the toxin blocks nerve transmissions
Bone Marrow for up to four months, so relieving symptoms.
Bone marrow is the soft substance occupying The toxin is also used in cerebral palsy.
the interior of bones. It is the site of formation Although very effective, there are many possible
of ERYTHROCYTES, granular LEUCOCYTES and unwanted effects, especially if too high a dose is
PLATELETS. used or the injection is misplaced.

Bone Marrow Transplant Botulism

The procedure by which malignant or defective A rare type of food poisoning with a mortality
bone marrow in a patient is replaced with nor- greater than 50 per cent, caused by the presence
mal bone marrow. Sometimes the patients own of the exotoxin of the anaerobic bacterium
marrow is used (when the disease is in remis- Clostridium botulinum, usually in contaminated
sion); after storage using tissue-freezing tech- tinned or bottled food. Symptoms develop a
nique (cryopreservation) it is reinfused into the few hours after ingestion.
patient once the diseased marrow has been The toxin has two components, one having
treated (autologous transplant). More com- haemagglutinin activity and the other neuro-
monly, a transplant uses marrow from a donor toxic activity which produces most of the symp-
whose tissue has been matched for compatibil- toms. It has a lethal dose of as little as 1 mg/kg
ity. The recipients marrow is destroyed with and is highly selective for cholinergic nerves.
CYTOTOXIC drugs before transfusion. The Thus the symptoms are those of autonomic
recipient is initially nursed in an isolated parasympathetic blockade (dry mouth, consti-
environment to reduce the risk of infection. pation, urinary retention, mydriasis, blurred
Disorders that can be helped or even cured vision) and progress to blockade of somatic
include certain types of LEUKAEMIA and many cholinergic transmission (muscle weakness).
inherited disorders of the immune system (see Death results from respiratory muscle paralysis.
IMMUNITY). Treatment consists of supportive measures and
 92 Bougies

4 aminopyridine and 3, 4 di-aminopyridine, demic reached its peak in 1992 when the inci-
which may antagonise the effect of the toxin. dence of newly diagnosed cases in cattle was
37,545.
B Bougies A two-year UK government inquiry into the
Solid instruments for introduction into natural BSE epidemic concluded that BSE had caused a
passages in the body in order either to apply harrowing fatal disease in humans, and criti-
medicaments which they contain or with which cised officials for misleading the public over the
they are coated, or, more usually, to dilate a risk to humans from BSE. Consequently, a
narrow part or stricture of the passage. Thus we compensation package for patients and relatives
have, for example, urethral bougies, oesopha- was made available. Meanwhile, a ban on the
geal bougies and rectal bougies, made usually of export of UK beef and restrictions on the type
flexible rubber or, in the case of the urethra, of of meat and products made from beef that can
steel. be sold to the public were put in place. Although
initially thought to be a problem primarily
Bovine Spongiform confined to the UK, several other countries
notably France, Germany, Spain, Switzerland
Encephalopathy (BSE) and the United States have also discovered
Known colloquially as mad cow disease, this is BSE in their cattle.
a fatal and untreatable disease. Along with scra-
pie in sheep and CREUTZFELDT-JACOB DISEASE Bowels
(CJD) in humans, BSE belongs to a class of See INTESTINE.
unusual degenerative diseases of the brain
known as transmissible spongiform encepha- Bowens Disease
lopathies. The disease is caused by abnormal An uncommon chronic localised skin disease,
PRION proteins, which are resistant to cellular presenting as a solitary chronic fixed irregular
degradation. These abnormal prion proteins plaque mimicking eczema or psoriasis. It is a
accumulate in and eventually cause the death of fairly benign form of CARCINOMA in situ in the
nerve cells, both in the spinal cord and the brain. EPIDERMIS but can occasionally become inva-
The rare human disease CJD occurs throughout sive. It is curable by CRYOTHERAPY or surgical
the world and is of three types: sporadic, iatro- excision.
genic (see IATROGENIC DISEASE) and inherited.
Since the BSE epidemic in cattle developed in Bow Leg
the UK in the 1980s, however, a new variant of Also known as genu varum: a deformity of
CJD has been identified and is believed to be the the legs which comprises outward curvature
result of consumption of the meat of BSE- between knee and ankle. It may be normal in
infected cattle. Studies in transgenic mice have infancy, and occurs in osteoarthritis, RICKETS
confirmed that BSE caused variant CJD. The and other metabolic bone diseases. In early
new variant has affected younger people and may childhood it may correct with growth, but in
have a shorter incubation period. If this incuba- other cases surgical correction by osteotomy or
tion period turns out to be the same as for the ephiphyseal stapling is possible.
other types of CJD, however, it could be 2005
2010 before the peak of this outbreak is reached. Boxing Injuries
Over 148 people had died, or were dying, from Boxing injuries rank eighth in frequency among
variant CJD in the UK by the year 2005. sports injuries. According to the Report on the
The appearance of BSE in cattle is believed Medical Aspects of Boxing issued by the Com-
to have been caused by a gene mutation (see mittee on Boxing of the Royal College of Phys-
GENETIC DISORDERS), although whether this icians of London in 1969, of 224 ex-
mutation first occurred in cattle or in some professional boxers examined, 37 showed evi-
other animal remains uncertain. Although the dence of brain damage and this was disabling in
first case of BSE was officially reported in 1985, 13.
the first cattle are thought to have been infected The first type of damage occurs as an acute
in the 1970s. BSE spread to epidemic propor- episode in which one or more severe blows leads
tions because cattle were fed meat and bone to loss of consciousness and occasionally to
meal, made from the offal of cattle suffering death. Death in the acute phase is usually due
from or incubating the disease. Mother-to-calf to intracranial haemorrhage and this carries a
transfer is another likely route of transmission, mortality of 45 per cent even with the sophisti-
although meat and bone meal in cattle feed cated surgical techniques currently available.
were the main cause of the epidemic. The epi- The second type of damage develops over a
 Brain 93

much longer period and is cumulative, leading Bradycardia

to the atrophy of the cerebral cortex and brain Slowness of the beating of the heart with cor-
stem. The repair processes of the brain are very responding slowness of the pulse (below 60 per
limited and even after mild concussion it may minute). (See HEART, DISEASES OF.) B
suffer a small amount of permanent structural
damage. Brain-scanning techniques now enable Bradykinesia
brain damage to be detected during life, and Bradykinesia refers to the slow, writhing
brain damage of the type previously associated movements of the body and limbs that may
with the punch-drunk syndrome is now being occur in various brain disorders (see
detected before obvious clinical signs have ATHETOSIS).
developed. Evidence of cerebral atrophy has
been found in relatively young boxers including Bradykinin
amateurs and those whose careers have been Bradykinin is a substance derived from plasma
considered successful. The tragedy is that brain proteins; it plays an important role in many of
damage can only be detected after it has the reactions of the body, including INFLAMMA-
occurred. Many doctors are opposed to boxing, TION. Its prime action is in producing dilata-
even with the present, more stringent medical tion of arteries and veins. It has also been
precautions taken by those responsible for run- described as the most powerful pain-producing
ning the sport. Since the Royal Colleges survey agent known.
in 1969, the British Medical Association and
other UK medical organisations have declared Braille
their opposition to boxing on medical grounds, A system of printing or writing devised for
as have medical organisations in several other blind people. Developed by the Frenchman
countries. Louis Braille, the system is based on six raised
In 1998, the Dutch Health Council recom- dots which can be organised in different com-
mended that professional boxing should be binations within two grades. Each system in
banned unless the rules are tightened. It Grade I represents an individual letter or punc-
claimed that chronic brain damage is seen in tuation mark. Grade IIs symbols represent
4080 per cent of boxers and that one in eight common combinations of letters or individual
amateur bouts end with a concussed words. Braille is accepted for all written lan-
participant. guages, mathematics, science and music, with
There is currently no legal basis on which to Grade II the more popular type.
ban boxing in the UK, although it has been
suggested that an injured boxer might one day Brain
sue a promoter. One correspondent to the Brit- The brain and spinal cord together form the
ish Medical Journal in 1998 suggested that central nervous sytem (CNS). Twelve cranial
since medical cover is a legal requirement at nerves leave each side of the brain (see NERVES,
boxing promotions, the profession should con- below) and 31 spinal nerves from each side of
sider if its members should withdraw the cord: together these nerves form the per-
participation. ipheral nervous system. Complex chains of
nerves lying within the chest and abdomen, and
Brachial acting largely independently of the peripheral
Brachial means belonging to the upper arm. system, though linked with it, comprise the
There are, for example, a brachial artery, and a AUTONOMIC NERVOUS SYSTEM and govern the
brachial plexus of nerves through which run activities of the VISCERA.
all the nerves to the arm. The brachial plexus The control centre of the whole nervous sys-
lies along the outer side of the armpit, and is tem is the brain, which is located in the skull or
liable to be damaged in dislocation at the cranium. As well as controlling the nervous sys-
shoulder. tem it is the organ of thought, speech and emo-
tion. The central nervous system controls the
Brachycephalic bodys essential functions such as breathing,
Brachycephalic means short-headed and is a body temperature (see HOMEOSTASIS) and the
term applied to skulls the breadth of which is at heartbeat. The bodys various sensations,
least four-fifths of the length. including sight, hearing, touch, pain, position-
ing and taste, are communicated to the CNS by
Brachydactyly nerves distributed throughout the relevant tis-
The conditions in which the fingers or toes are sues. The information is then sorted and inter-
abnormally short. preted by specialised areas in the brain. In
 94 Brain

response these initiate and coordinate the above lies the PINEAL GLAND. This region
motor output, triggering such voluntary activ- includes the important HYPOTHALAMUS.
ities as movement, speech, eating and swallow-
B ing. Other activities for example, breathing, MID-BRAIN or mesencephalon: a stalk about 20
digestion, heart contractions, maintenance of mm long connecting the cerebrum with the
BLOOD PRESSURE, and filtration of waste hind-brain. Down its centre lies a tube, the
products from blood passing through the kid- cerebral aqueduct, or aqueduct of Sylvius, con-
neys are subject to involuntary control via necting the third and fourth ventricles. Above
the autonomic system. There is, however, this aqueduct lie the corpora quadrigemina, and
some overlap between voluntary and involun- beneath it are the crura cerebri, strong bands of
tary controls. white matter in which important nerve fibres
pass downwards from the cerebrum. The pineal
Divisions gland is sited on the upper part of the mid-
CEREBRUM This forms nearly 70 per cent of brain.
the brain and consists of two cerebral hemi-
spheres which occupy the entire vault of the PONS A mass of nerve fibres, some of which run
cranium and are incompletely separated from crosswise and others are the continuation of the
one another by a deep mid-line cleft, the longi- crura cerebri downwards.
tudinal cerebral fissure. At the bottom of this
cleft the two hemispheres are united by a thick CEREBELLUM This lies towards the back,
band of some 200 million crossing nerve fibres underneath the occipital lobes of the cerebrum.
the corpus callosum. Other clefts or fissures
(sulci) make deep impressions, dividing the MEDULLA OBLONGATA The lowest part of the
cerebrum into lobes. The lobes of the cerebrum brain, in structure resembling the spinal cord,
are the frontal lobe in the forehead region, the with white matter on the surface and grey mat-
parietal lobe on the side and upper part of ter in its interior. This is continuous through
the brain, the occipital lobe to the back, and the the large opening in the skull, the foramen
temporal lobe lying just above the region of magnum, with the spinal cord. Between the
the ear. The outer 3 mm of the cerebrum is medulla, pons, and cerebellum lies the fourth
called the cortex, which consists of grey matter ventricle of the brain.
with the nerve cells arranged in six layers. This
region is concerned with conscious thought, Structure The grey matter consists mainly of
sensation and movement, operating in a similar billions of neurones (see NEURON(E)) in which
manner to the more primitive areas of the brain all the activities of the brain begin. These cells
except that incoming information is subject to vary considerably in size and shape in different
much greater analysis. parts of the brain, though all give off a number
Numbers of shallower infoldings of the sur- of processes, some of which form nerve fibres.
face, called furrows or sulci, separate raised areas The cells in the cortex of the cerebral hemi-
called convolutions or gyri. In the deeper part, spheres, for example, are very numerous, being
the white matter consists of nerve fibres con- set in layers five or six deep. In shape these cells
necting different parts of the surface and pass- are pyramidal, giving off processes from the
ing down to the lower parts of the brain. apex, from the centre of the base, and from
Among the white matter lie several rounded various projections elsewhere on the cell. The
masses of grey matter, the lentiform and caud- grey matter is everywhere penetrated by a rich
ate nuclei. In the centre of each cerebral hemi- supply of blood vessels, and the nerve cells and
sphere is an irregular cavity, the lateral ventricle, blood vessels are supported in a fine network of
each of which communicates with that on the fibres known as neuroglia.
other side and behind with the third ventricle The white matter consists of nerve fibres,
through a small opening, the inter-ventricular each of which is attached, at one end, to a cell in
foramen, or foramen of Monro. the grey matter, while at the other end it splits
up into a tree-like structure around another cell
BASAL NUCLEI Two large masses of grey matter in another part of the grey matter in the brain
embedded in the base of the cerebral hemi- or spinal cord. The fibres have insulating
spheres in humans, but forming the chief part sheaths of a fatty material which, in the mass,
of the brain in many animals. Between these gives the white matter its colour; they convey
masses lies the third ventricle, from which the messages from one part of the brain to the other
infundibulum, a funnel-shaped process, pro- (association fibres), or, grouped into bundles,
jects downwards into the pituitary body, and leave the brain as nerves, or pass down into the
 Brain, Diseases of 95

spinal cord where they end near, and exert a bral veins, bring the blood away from the
control upon, cells from which in turn spring interior of the brain, but most of the small veins
the nerves to the body. come to the surface and open into large venous
Both grey and white matter are bound sinuses, which run in grooves in the skull, and B
together by a network of cells called GLIA which finally pass their blood into the internal jugular
make up 60 per cent of the brains weight. vein that accompanies the carotid artery on
These have traditionally been seen as simple each side of the neck.
structures whose main function was to glue the
constituents of the brain together. Recent MEMBRANES The brain is separated from the
research, however, suggests that glia are vital for skull by three membranes: the dura mater, a
growing synapses between the neurons as they thick fibrous membrane; the arachnoid mater, a
trigger these cells to communicate with each more delicate structure; and the pia mater,
other. So they probably participate in the task adhering to the surface of the brain and con-
of laying down memories, for which synapses taining the blood vessels which nourish it.
are an essential key. The research points to the Between each pair is a space containing fluid on
likelihood that glial cells are as complex as which the brain floats as on a water-bed. The
neurons, functioning biochemically in a similar fluid beneath the arachnoid membrane mixes
way. Glial cells also absorb potassium pumped with that inside the ventricles through a small
out by active neurons and prevent levels of opening in the fourth ventricle, called the
GLUTAMATE the most common chemical median aperture, or foramen of Magendie.
messenger in the brain from becoming too These fluid arrangements have a great influ-
high. ence in preserving the brain from injury.
The general arrangement of fibres can be best
understood by describing the course of a motor NERVES Twelve nerves come off the brain:
nerve-fibre. Arising in a cell on the surface in I. Olfactory, to the nose (smell).
front of the central sulcus, such a fibre passes II. Optic, to the eye (sight).
inwards towards the centre of the cerebral III. Oculomotor
hemisphere, the collected mass of fibres as they IV. Trochlear, to eye-muscles.
lie between the lentiform nucleus and optic V. Abducent
thalamus being known as the internal capsule. VI. Trigeminal, to skin of face.
Hence the fibre passes down through the crus VII. Facial, to muscles of face.
cerebri, giving off various small connecting VIII. Vestibulocochlear, to ear (hearing and
fibres as it passes downwards. After passing balancing).
through the pons it reaches the medulla, and at IX. Glossopharyngeal, to tongue (taste).
this point crosses to the opposite side (decussa- X. Vagus, to heart, larynx, lungs, and
tion of the pyramids). Entering the spinal cord, stomach.
it passes downwards to end finally in a series of XI. Spinal accessory, to muscles in neck.
branches (arborisation) which meet and touch XII. Hypoglossal, to muscles of tongue.
(synapse) similar branches from one or more of
the cells in the grey matter of the cord (see Brain, Diseases of
SPINAL CORD). These consist either of expanding masses
(lumps or tumours), or of areas of shrinkage
BLOOD VESSELS Four vessels carry blood to the (atrophy) due to degeneration, or to loss of
brain: two internal carotid arteries in front, and blood supply, usually from blockage of an
two vertebral arteries behind. These communi- artery.
cate to form a circle (circle of Willis) inside the
skull, so that if one is blocked, the others, by Tumours All masses cause varying combin-
dilating, take its place. The chief branch of the ations of headache and vomiting symptoms of
internal carotid artery on each side is the mid- raised pressure within the inexpansible bony
dle cerebral, and this gives off a small but very box formed by the skull; general or localised
important branch which pierces the base of the epileptic fits; weakness of limbs or disordered
brain and supplies the region of the internal speech; and varied mental changes. Tumours
capsule with blood. The chief importance of may be primary, arising in the brain, or second-
this vessel lies in the fact that the blood in it is ary deposits from tumours arising in the lung,
under especially high pressure, owing to its breast or other organs. Some brain tumours are
close connection with the carotid artery, so that benign and curable by surgery: examples
haemorrhage from it is liable to occur and thus include meningiomas and pituitary tumours.
give rise to stroke. Two veins, the internal cere- The symptoms depend on the size and situation
 96 Brain, Diseases of

of the mass. Abscesses or blood clots (see Parkinsons disease, hereditary Huntingtons
HAEMATOMA) on the surface or within the chorea, or, in children with birth defects of the
brain may resemble tumours; some are remov- brain, athetosis and dystonias. Modern drugs,
B able. Gliomas ( see GLIOMA) are primary malig- such as DOPAMINE drugs in PARKINSONISM, and
nant tumours arising in the glial tissue (see GLIA) other treatments can improve the symptoms
which despite surgery, chemotherapy and radio- and reduce the disabilities of some of these
therapy usually have a bad prognosis, though diseases.
some astrocytomas and oligodendronogliomas
are of low-grade malignancy. A promising line Drugs and injury Alcohol in excess, the
of research in the US (in the animal-testing abuse of many sedative drugs and artificial brain
stage in 2000) suggests that the ability of stem stimulants such as cocaine, LSD and heroin
cells from normal brain tissue to home in on (see DEPENDENCE) can damage the brain; the
gliomal cells can be turned to advantage. The effects can be reversible in early cases. Severe
stem cells were chemically manipulated to carry head injury can cause localised or diffuse brain
a poisonous compound (5-fluorouracil) to the damage (see HEAD INJURY).
gliomal cells and kill them, without damaging
normal cells. Around 80 per cent of the cancer- Cerebral palsy Damage to the brain in
ous cells in the experiments were destroyed in children can occur in the uterus during preg-
this way. nancy, or can result from rare hereditary and
Clinical examination and brain scanning genetic diseases, or can occur during labour and
(CT, or COMPUTED TOMOGRAPHY; magnetic delivery. Severe neurological illness in the early
resonance imaging (MRI) and functional MRI) months of life can also cause this condition in
are safe, accurate methods of demonstrating the which stiff spastic limbs, movement disorders
tumour, its size, position and treatability. and speech defects are common. Some of these
children are learning-disabled.
Strokes When a blood vessel, usually an
artery, is blocked by a clot, thrombus or embol- Dementias In older people a diffuse loss of
ism, the local area of the brain fed by that artery cells, mainly at the front of the brain, causes
is damaged (see STROKE). The resulting infarct ALZHEIMERS DISEASE the main feature being
(softening) causes a stroke. The cells die and a loss of memory, attention and reasoned judge-
patch of brain tissue shrinks. The obstruction ment (dementia). This affects about 5 per cent
in the blood vessel may be in a small artery in of the over-80s, but is not simply due to ageing
the brain, or in a larger artery in the neck. processes. Most patients require routine tests
Aspirin and other anti-clotting drugs reduce and brain scanning to indicate other, treatable
recurrent attacks, and a small number of people causes of dementia.
benefit if a narrowed neck artery is cleaned out Response to current treatments is poor, but
by an operation endarterectomy. Similar promising lines of treatment are under devel-
symptoms develop abruptly if a blood vessel opment. Like Parkinsonism, Alzheimers dis-
bursts, causing a cerebral haemorrhage. The ease progresses slowly over many years. It is
symptoms of a stroke are sudden weakness or uncommon for these diseases to run in families.
paralysis of the arm and leg of the opposite side Multiple strokes can cause dementia, as can
to the damaged area of brain (HEMIPARESIS), some organic disorders such as cirrhosis of the
and sometimes loss of half of the field of vision liver.
to one side (HEMIANOPIA). The speech area is in
the left side of the brain controlling language in Infections in the brain are uncommon. Vir-
right-handed people. In 60 per cent of left- uses such as measles, mumps, herpes, human
handers the speech area is on the left side, and immunodeficiency virus and enteroviruses may
in 40 per cent on the right side. If the speech cause ENCEPHALITIS a diffuse inflammation
area is damaged, difficulties both in under- (see also AIDS/HIV).
standing words, and in saying them, develops Bacteria or viruses may infect the membrane
(see DYSPHASIA). covering the brain, causing MENINGITIS. Viral
meningitis is normally a mild, self-limiting
Degenerations (atrophy) For reasons infection lasting only a few days; however, bac-
often unknown, various groups of nerve cells terial meningitis caused by meningococcal
degenerate prematurely. The illness resulting is groups B and C, pneumococcus, and (now
determined by which groups of nerve cells are rarely) haemophilus is a life-threatening con-
affected. If those in the deep basal ganglia are dition. Antibiotics have allowed a cure or good
affected, a movement disorder occurs, such as control of symptoms in most cases of menin-
 Brain-Stem Death 97

gitis, but early diagnosis is essential. Severe Severe head injuries cause unconscious-
headaches, fever, vomiting and increasing ness for hours or many days, followed by loss of
sleepiness are the principal symptoms which memory before and after that period of
demand urgent advice from the doctor, and unconsciousness. The skull may be fractured; B
usually admission to hospital. Group B menin- there may be fits in the first week; and there
gococcus is the commonest of the bacterial may develop a blood clot in the brain (intracer-
infections, but Group C causes more deaths. A ebral haematoma) or within the membranes
vaccine against the latter has been developed covering the brain (extradural and subdural
and has reduced the incidence of cases by 75 haematomata). These clots compress the brain,
per cent. and the pressure inside the skull intracranial
If infection spreads from an unusually serious pressure rises with urgent, life-threatening
sinusitis or from a chronically infected middle consequences. They are identified by neurolo-
ear, or from a penetrating injury of the skull, an gists and neurosurgeons, confirmed by brain
abscess may slowly develop. Brain abscesses scans (see COMPUTED TOMOGRAPHY; MRI), and
cause insidious drowsiness, headaches, and at a require urgent surgical removal. Recovery may
late stage, weakness of the limbs or loss of be complete, or in very severe cases can be
speech; a high temperature is seldom present. marred by physical disabilities, EPILEPSY, and by
Early diagnosis, confirmed by brain scanning, is changes in intelligence, rational judgement and
followed by antibiotics and surgery in hospital, behaviour. Symptoms generally improve in the
but the outcome is good in only half of affected first two years.
patients. A minority of those with minor head injuries
have complaints and disabilities which seem
Cerebral oedema Swelling of the brain can disproportionate to the injury sustained.
occur after injury, due to engorgement of blood Referred to as the post-traumatic syndrome,
vessels or an increase in the volume of the this is not a diagnostic entity. The complaints
extravascular brain tissue due to abnormal are headaches, forgetfulness, irritability, slow-
uptake of water by the damaged grey (neurons) ness, poor concentration, fatigue, dizziness
matter and white (nerve fibres) matter. This lat- (usually not vertigo), intolerance of alcohol,
ter phenomenon is called cerebral oedema and light and noise, loss of interests and initiative,
can seriously affect the functioning of the DEPRESSION, anxiety, and impaired LIBIDO.
brain. It is a particularly dangerous complica- Reassurance and return to light work help
tion following injury because sometimes an these symptoms to disappear, in most cases
unconscious person whose brain is damaged within three months. Psychological illness and
may seem to be recovering after a few hours, unresolved compensation-claims feature in
only to have a major relapse. This may be the many with implacable complaints.
result of a slow haemorrhage from damaged People who have had brain injuries, and their
blood vessels raising intracranial pressure, or relatives, can obtain help and advice from
because of oedema of the brain tissue in the Headwat and from www.neuro.pmr.vcu.edu
area surrounding the injury. Such a develop- and www.biausa.org
ment is potentially lethal and requires urgent
specialist treatment to alleviate the rising intra- Brain-Stem Death
cranial pressure: osmotic agents (see OSMOSIS) Brain damage, resulting in the irreversible loss
such as mannitol or frusemide are given intra- of brain function, renders the individual
venously to remove the excess water from the incapable of life without the aid of a VENTILA-
brain and to lower intracranial pressure, buying TOR. Criteria have been developed to recognise
time for definitive investigation of the cranial that death has occurred and to allow ventila-
damage. tion to be stopped: in the UK, these criteria
require the patient to be irreversibly
Brain Injuries unconscious and unable to regain the capacity
Most blows to the head cause no loss of con- to breathe spontaneously. (See also GLASGOW
sciousness and no brain injury. If someone is COMA SCALE and PERSISTENT VEGETATIVE
knocked out for a minute or two, there has STATE (PVS).)
been a brief disturbance of the brain cells (con- All reversible pharmacological, metabolic,
cussion); usually there are no after-effects. Most endocrine and physiological causes must be
patients so affected leave hospital within 13 excluded, and there should be no doubt that
days, have no organic signs, and recover and irreversible brain damage has occurred. Two
return quickly to work without further senior doctors carry out diagnostic tests to con-
complaints. firm that brain-stem reflexes are absent. These
 98 Bran

tests must be repeated after a suitable interval milk following childbirth. Each breast consists
before death can be declared. Imaging tech- of 1220 compartments arranged radially
niques are not required for death to be diag- around the nipple: each compartment opens on
B nosed. The test for brain-stem death are: to the tip of the nipple via its own duct through
Fixed dilated pupils of the eyes which the milk flows. The breast enlargement
Absent CORNEAL REFLEX that occurs in pregnancy is due to development
Absent VESTIBULO-OCULAR REFLEX of the glandular part in preparation for lacta-
No cranial motor response to somatic (phys- tion. In women beyond childbearing age, the
ical) stimulation glandular part of the breasts reduces (called
Absent gag and cough reflexes involution) and the breasts become less firm
No respiratory effort in response to APNOEA
despite adequate concentrations of CARBON
and contain relatively more fat.

DIOXIDE in the arterial blood. Breasts, Diseases of

The female breasts may be expected to undergo
Bran hormone-controlled enlargement at puberty,
The meal derived from the outer covering of a and later in pregnancy, and the glandular part
cereal grain. It contains little or no carbo- of the breast undergoes evolution (shrinkage)
hydrate, and is mainly used to provide ROUGH- after the menopause. The breast can also be
AGE in the control of bowel function and the affected by many different diseases, with com-
prevention of constipation. mon symptoms being pain, nipple discharge or
retraction, and the formation of a lump within
Branchial Cyst the breast.
A cyst arising in the neck from remnants of the
embryological branchial clefts. They are usually Benign disease is much more common
fluid-filled and will therefore transilluminate. than cancer, particularly in young women, and
includes acute inflammation of the breast (mas-
Breasts titis); abscess formation; and benign breast
Breasts, or mammary glands, occur only in lumps, which may be fibroadenosis diffuse
mammals and provide milk for feeding the lumpiness also called chronic mastitis or fibro-
young. These paired organs are usually fully cystic disease in which one or more fluid-
developed only in adult females, but are present filled sacs (cysts) develop.
in rudimentary form in juveniles and males. In Women who are breast feeding are particu-
women, the two breasts over-lie the second to larly prone to mastitis, as infection may enter
sixth ribs on the front of the chest. On the sur- the breast via the nipple. The process may be
face of each breast is a central pink disc called arrested before a breast abscess forms by prompt
the areola, which surrounds the nipple. Inside, treatment with antibiotics. Non-bacterial
the breast consists of fat, supporting tissue and inflammation may result from mammary duct
glandular tissue, which is the part that produces ectasia (dilatation), in which abnormal or

Lateral view of female breast showing internal structure and chest wall.
 Breasts, Diseases of 99

blocked ducts may overflow. Initial treatments Malignant disease most commonly but
should be with antibiotics, but if an abscess not exclusively occurs in post-menopausal
does form it should be surgically drained. women, classically presenting as a slowly grow-
Duct ectasia, with or without local mastitis, ing, painless, firm lump. A bloodstained nipple B
is the usual benign cause of various nipple discharge or eczematous skin change may also
complaints, with common symptoms being be suggestive of cancer.
nipple retraction, discharge and skin change. The most commonly used classification of
Breast lumps form the chief potential danger invasive cancers has split them into two types,
and may be either solid or cystic. Simple exam- ductal and lobular, but this is no longer suit-
ination may fail to distinguish the two types, able. There are also weaknesses in the tumour
but aspiration of a benign cyst usually results in node metastases (TNM) system and the Inter-
its disappearance. If the fluid is bloodstained, or national Union Against Cancer (UICC)
if a lump still remains, malignancy is possible, classification.
and all solid lumps need histological (tissue The TNM system which classifies the
examination) or cytological (cell examination) lump by size, fixity and presence of affected axil-
assessment. As well as having their medical lary glands and wider metastatic spread is best
and family history taken, any women with a combined with a pathological classification,
breast lump should undergo triple assessment: when assessing the seriousness of a possibly
a combination of clinical examination, imaging cancerous lump. Risk factors for cancer include
mammography for the over-35s and ultrason- nulliparity (see NULLIPARA), first pregnancy over
agraphy for the under-35s and fine-needle the age of 30 years, early MENARCHE, late
aspiration. The medical history should include MENOPAUSE and positive family history. The
details of any previous lumps, family history danger should be considered in women who are
(up to 10 per cent of breast cancer in western not breast feeding or with previous breast can-
countries is due to genetic disposition), pain, cer, and must be carefully excluded if the
nipple discharge, change in size related to men- woman is taking any contraceptive steroids or
strual cycle and parous state, and any drugs is on hormone-replacement therapy (see under
being taken by the patient. Breasts should be MENOPAUSE).
inspected with the arms up and down, noting Screening programmes involving mammog-
position, size, consistency, mobility, fixity, and raphy are well established, the aim being to
local lymphadenopathy (glandular swelling). detect more tumours at an early and curable
Nipples should be examined for the presence of stage. Pick-up rate is five per 1,000 healthy
inversion or discharge. Skin involvement (peau women over 50 years. Yearly two-view mam-
dorange) should be noted, and, in particular, mograms could reduce mortality by 40 per cent
how long changes have been present. Fine- but may cause alarm because there are ten false
needle aspiration and cytological examination positive mammograms for each true positive
of the fluid are essential with ULTRASOUND, result. In premenopausal women, breasts are
MAMMOGRAPHY and possible BIOPSY being denser, making mammograms harder to inter-
considered, depending on the patients age and pret, and screening appears not to save lives.
the extent of clinical suspicion that cancer may About a quarter of women with a palpable
be present. breast lump turn out to have cancer.
The commonest solid benign lump is a
fibroadenoma, particularly in women of child- Treatment This remains controversial, and
bearing age, and is a painless, mobile lump. If all options should be carefully discussed with
small, it is usually safe to leave it alone, pro- the patient and, where appropriate, with her
vided that the patient is warned to seek medical partner. Locally contained disease may be
advice if its size or character changes or if the treated by local excision of the lump, but sam-
lump becomes painful. Fibroadenosis (diffuse pling of the glands of the armpit of the same
lumpiness often in the upper, outer quadrant) is side should be performed to check for add-
a common (benign) lump. Others include peri- itional spread of the disease, and hence the need
ductal mastitis, fat NECROSIS, GALACTOCELE, for CHEMOTHERAPY or RADIOTHERAPY.
ABSCESS, and non-breast-tissue lumps for Depending on the extent of spread, simple
example, a LIPOMA (fatty tissue) or SEBACEOUS mastectomy or modified radical mastectomy
CYST. A woman with breast discharge should (which removes the lymph nodes draining the
have a mammograph, ductograph, or total duct breast) may be required. Follow-up chemo-
excision until the cause of any underlying duct therapy, for example, with TAMOXIFEN (an oes-
ectasia is known. Appropriate treatment should trogen antagonist), much improves survival (it
then be given. saves 12 lives over 100 women treated), though
 100 Breastbone

it may occasionally cause endometrial carcin- Breast Screening

oma. Analysis in the mid-1990s of large-scale A set of investigations aimed at the early detec-
international studies of breast-cancer treat- tion of breast cancer. It includes self-screening
B ments showed wide variations in their by monthly examination of the breasts, and
effectiveness. As a result the NHS has encour- formal programmes of screening by palpation
aged hospitals to set up breast-treatment teams and mammography in special clinics. In the UK
containing all the relevant health professional the NHS offers regular mammography examin-
experts and to use those treatments shown to be ations to all women between 50 and 64 years of
most effective. age; in 19956, 1.1 million women were
As well as the physical treatments provided, screened 76 per cent of those invited. More
women with suspected or proven breast cancer than 5,500 cancers were detected 5.3 per
should be offered psychological support 1,000 women screened.
because up to 30 per cent of affected women
develop an anxiety state or depressive illness Breath-Holding
within a year of diagnosis. Problems over body Breath-holding attacks are not uncommon in
image and sexual difficulties occur in and infants and toddlers. They are characterised by
around one-quarter of patients. Breast conserva- the child suddenly stopping breathing in the
tion and reconstructive surgery can improve the midst of a bout of crying evoked by pain, some
physical effects of mastectomy, and women emotional upset, or loss of temper. The breath
should be advised on the prostheses and spe- may be held so long that the child goes blue in
cially designed brassieres that are available. Spe- the face. The attack is never fatal and the condi-
cialist nurses and self-help groups are invaluable tion disappears spontaneously after the age of
in supporting affected women and their part- 35 years, but once a child has acquired the
ners with the problems caused by breast cancer habit it may recur quite often.
and its treatment. Breast Cancer Care, British It is important for a paediatrician to deter-
Association of Cancer United Patients mine that such events are not epileptic (see EPI-
(BACUP), Cancerlink, and Cancer Relief LEPSY). Generally they require no treatment
Macmillan Fund are among voluntary organisa- other than reassurance, as recovery is spon-
tions providing support. taneous and rapid although a small number of
severely affected children have been helped by a
Breastbone PACEMAKER. Parents should avoid dramatising
See STERNUM. the attacks.

Breast Feeding Breathing

This is the natural way to feed a baby from See RESPIRATION.
birth to WEANING. Human milk is an ideal
food, containing a proper balance of nutrients Breathlessness
as well as an essential supply of antibodies to Breathlessness, or dyspnoea, may be due to any
protect the infant against infections. Breast condition which renders the blood deficient in
feeding also strengthens the physical bond oxygen, and which therefore produces excessive
between mother and child. For the first few involuntary efforts to gain more air. Exercise is a
weeks, feeding should be on demand. Difficul- natural cause, and acute anxiety may provoke
ties over breast feeding, discouragement from breathlessness in otherwise healthy people.
health-care providers and the pressures of Deprivation of oxygen for example, in a
modern life, especially for working mothers, building fire will also cause the victim to raise
can make it hard to continue breast feeding his or her breathing rate. Disorders of the lung
for more than a few weeks, or even to breast may diminish the area available for breathing
feed at all. Sometimes infections occur, pro- for example, ASTHMA, PNEUMONIA, TUBERCU-
ducing soreness and even an abscess. Mothers LOSIS, EMPHYSEMA, BRONCHITIS, collections of
should seek advice from their health visitor fluid in the pleural cavities, and pressure caused
about breast feeding, especially if problems by a TUMOUR or ANEURYSM.
arise. Pleurisy causes short, rapid breathing to
avoid the pain of deep inspiration.
Breast Reconstruction
See MAMMOPLASTY.
Narrowing of the air passages may produce
sudden and alarming attacks of difficult
breathing, especially among children for
Breast Reduction example, in CROUP, asthma and
See MAMMOPLASTY. DIPHTHERIA.
 Bronchiectasis 101

OF
Most cardiac disorders (see HEART, DISEASES
) cause breathlessness, especially when the
and rINN were identical; where there was a dif-
ference, the rINN nomenclature is now used.
person undergoes any special exertion. An exception is adrenaline, which remains the
Anaemia is a frequent cause. official name in Europe with the rINN epi- B
Obesity is often associated with shortness of nephrine being a synonym.
breath.
Mountain climbing may cause breathlessness British Dental Association
because, as altitude increases, the amount of See APPENDIX 8: PROFESSIONAL ORGANISATIONS.
oxygen in the air falls (see ALTITUDE SICKNESS).
(See also LUNGS and RESPIRATION.) British Medical Association
(BMA)
Breath Sounds See APPENDIX 8: PROFESSIONAL ORGANISATIONS.
The transmitted sounds of breathing, heard
when a stethoscope is applied to the chest.
Normal breath sounds are described as vesicu-
British National Formulary (BNF)
A pocket-book for those concerned with the
lar. Abnormal sounds may be heard when there prescribing, dispensing and administration of
is increased fluid in the lungs or fibrosis (crepi- medicines in Britain. It is produced jointly by
tation or crackles), when there is bronchospasm the Royal Pharmaceutical Society and the Brit-
(rhonchi or wheezes), or when the lung is airless ish Medical Association, is revised twice yearly
(consolidated bronchial breathing). Breath and is distributed to NHS doctors by the
sounds are absent in people with pleural effu- Health Departments. The BNF is also available
sion, pneumothorax, or after pneumonectomy. in electronic form.
Breech Delivery
See BREECH PRESENTATION.
British Pharmacopoeia
See PHARMACOPOEIA.
Breech Presentation
By the 32nd week of pregnancy most babies are British Thermal Unit (BTU)
in a head-down position in the womb. Up to 4 An officially recognised measurement of heat: a
per cent of them, however, have their buttocks unit is equal to the quantity of heat needed to
(breech) presenting at the neck of the womb. If raise the temperature of one pound of water by
the baby is still a breech presentation at the 1Fahrenheit. One BTU is equivalent to 1,055
34th to 35th week the obstetrician may, by joules (see JOULE).
external manipulation, try to turn it to the
head-down position. If this is not successful, Brittle Bone Disease
the fetus is left in the breech position. Breech Brittle Bone Disease is another name for
deliveries are more difficult for mother and OSTEOGENESIS IMPERFECTA.
baby because the buttocks are less efficient than
the head at dilating the cervix and vagina. An Bromocriptine
EPISIOTOMY is usually necessary to assist deliv- A drug that stimulates DOPAMINE receptors in
ery, and obstetric FORCEPS may also have to be the brain. It inhibits production of the hor-
applied to the babys head. If the infant and/or mone PROLACTIN and is used to treat GALACT-
the mother become unduly distressed, the ORRHOEA (excessive milk secretion) and also to
obstetrician may decide to deliver the baby by suppress normal LACTATION. The drug is help-
CAESAREAN SECTION; some obstetricians prefer ful in treating premenstrual breast engorgement
to deliver most breech-presentation babies and also ACROMEGALY.
using this method. (See PREGNANCY AND
LABOUR.) Bronchial Tubes
See AIR PASSAGES; BRONCHUS; LUNGS.
Brights Disease
See KIDNEYS, DISEASES OF Glomerulonephritis. Bronchiectasis
A condition characterised by dilatation of the
British Approved Names (BAN) bronchi (see BRONCHUS). As a rule, this is the
The officially approved name for a medicinal result of infection of the bronchial tree leading
substance used in the UK. A 1992 European to obstruction of the bronchi. Due to the
Union directive required the use of a Recom- obstruction, the affected individual cannot get
mended International Non-proprietary Name rid of the secretions in the bronchi beyond the
(rINN) for these substances. Usually the BAN obstruction; these accumulate and become
 102 Bronchioles

infected. The initial infection may be due to chronic ASTHMA and EMPHYSEMA are the
bacterial or viral pneumonia or to the infection others.
of the lungs complicating measles or whooping- In the past, industrial workers regularly
B cough. Once a common disease, immunisation exposed to heavily polluted air commonly
of infants against infectious diseases and the developed bronchitis. The main aetiological
use of antibiotics have greatly reduced the factor is smoking; this leads to an increase in
incidence of bronchiectasis. (See CHRONIC size and number of bronchial mucous glands.
OBSTRUCTIVE PULMONARY DISEASE (COPD).) These are responsible for the excessive mucus
production within the bronchial tree, causing a
Treatment consists of postural drainage of persistent productive cough. The increased
excessive lung secretions, and antibiotics. number of mucous glands along with the influx
of inflammatory cells may lead to airway-
Bronchioles narrowing: when airway-narrowing occurs, it
The term applied to the finest divisions of the slows the passage of air, producing breathless-
bronchial tubes of the LUNGS. ness. Other less important causative factors
include exposure to pollutants and dusts. Infec-
Bronchiolitis tions do not cause the disease but frequently
The name sometimes applied to bronchitis produce exacerbations with worsening of
affecting the finest bronchial tubes, also known symptoms.
as capillary bronchitis. Major epidemics occur
every winter in Northern Europe in babies Treatments involve the use of antibiotics to
under 18 months due to respiratory syncytial treat the infections that produce exacerbations
virus (RSV). Many are admitted to hospital; of symptoms. Bronchodilators (drugs that open
some need artificial ventilation for a time and a up the airways) help to reverse the airway-
very small number die. narrowing that causes the breathlessness.
PHYSIOTHERAPY is of value in keeping the air-
Bronchiolitis Obliterans ways clear of MUCUS. Cessation of smoking
A rare disorder involving gradually increasing reduces the speed of progression.
FIBROSIS and destruction of lung tissue follow-
ing an attack of BRONCHIOLITIS. Bronchodilator
This type of drug reduces the tone of smooth
Bronchitis muscle in the lungs BRONCHIOLES and there-
Inflammation of the bronchial tubes (see AIR fore increases their diameter. Such drugs are
PASSAGES; BRONCHUS; LUNGS). This may occur used in the treatment of diseases that cause
as an acute transient illness or as a chronic bronchoconstriction, such as ASTHMA and
condition. BRONCHITIS. As bronchiolar tone is a balance
between sympathetic and parasympathetic
Acute bronchitis is due to an acute infec- activity, most bronchodilators are either B2
tion viral or bacterial of the bronchi. This is receptor agonists or cholinergic receptor ant-
distinguished from PNEUMONIA by the anatom- agonists although theophyllines are also
ical site involved: bronchitis affects the bronchi useful.
whilst pneumonia affects the lung tissue. The
infection causes a productive cough, and fever. Bronchography
Secretions within airways sometimes lead to A radiographic procedure using a radio-opaque
wheezing. Sometimes the specific causative substance injected into the bronchial tree to
organism may be identified from the sputum. show its outline. This is a simple procedure car-
The illness is normally self-limiting but, if ried out under general anaesthesia and allows
treatments are required, bacterial infections the accurate location of, for example, a lung
respond to a course of antibiotics. ABSCESS, BRONCHIECTASIS, or a TUMOUR in the
lung.
Chronic bronchitis is a clinical diagnosis
applied to patients with chronic cough and spu- Bronchopleural Fistula
tum production. For epidemiological studies it An abnormal communication between the
is defined as cough productive of sputum on tracheo-bronchial tree and the pleural cavity (see
most days during at least three consecutive LUNGS). Most commonly occurring from
months for not less than two consecutive years. breakdown of the bronchial stump following
Chronic bronchitis is classified as a CHRONIC pneumonectomy, it may also be caused by
PULMONARY OBSTRUCTIVE DISEASE (COPD); trauma, neoplasia or inflammation.
 Bruxism 103

Broncho-Pneumonia Symptoms The characteristic features of the

See PNEUMONIA. disease are undulating fever, drenching sweats,
pains in the joints and back, and headache. The
Bronchoscope liver and spleen may be enlarged. The diagnosis B
An instrument constructed on the principle of is confirmed by the finding of Br. abortus, or
the telescope, which on introduction into the antibodies to it, in the blood. Recovery and
mouth is passed down through the LARYNX and convalescence tend to be slow.
TRACHEA and enables the observer to see the
interior of the larger bronchial tubes. The bron- Treatment The condition responds well to
choscope has largely been superseded by fibr- one of the tetracycline antibiotics, and also to
eoptic bronchoscopy. (See ENDOSCOPE.) gentamicin and co-trimoxazole, but relapse is
common. In chronic cases a combination of
Bronchoscopy streptomycin and one of the tetracyclines is
The use of a bronchoscope to visualise the often more effective.
interior of the bronchial tubes.
Prevention It can be prevented by boiling or
Bronchospasm pasteurising all milk used for human consump-
Muscular contraction of the bronchi (air pas- tion. In Scandinavia, the Netherlands, Switzer-
sages) in the LUNGS, causing narrowing. The land and Canada the disease has disappeared
cause is usually a stimulus, as in BRONCHITIS following its eradication in animals. Brucellosis
and ASTHMA. The result is that the patient can has been eradicated from farm animals in the
inhale air into the lungs but breathing out United Kingdom.
becomes difficult and requires muscular effort
of the chest. Exhalation is accompanied by aud- Bruises
ible noises in the airways which can be detected Bruises, or contusions, result from injuries to
with a STETHOSCOPE. Reversible obstructive the deeper layers of the skin or underlying tis-
airways disease can be relieved with a BRON- sues, with variable bleeding but without open
CHODILATOR drug; if the bronchospasm cannot wounds. Bruises range from a slight bluish dis-
be relieved by drugs it is called irreversible. (See coloration, due to minimal trauma and haem-
CHRONIC OBSTRUCTIVE PULMONARY DISEASE orrhage, to a large black swelling in more severe
(COPD).) cases. Diseases such as HAEMOPHILIA and
SCURVY, which reduce COAGULATION, should
Bronchus be suspected when extensive bruises are pro-
Bronchus, or bronchial tube, is the name duced by minor injuries. Bruises change colour
applied to tubes into which the TRACHEA div- from blue-black to brown to yellow, gradually
ides, one going to either lung. The name is also fading as the blood pigment is broken down
applied to the divisions of these tubes distrib- and absorbed. Bruising in the abdomen or in
uted throughout the lungs, the smallest being the back in the area of the kidneys should
called bronchioles. prompt the examining doctor to assess whether
there has been any damage to internal tissues or
Brucellosis organs. Bruising in children, especially repeated
Also known as undulant fever, or Malta fever. bruising, may be caused by physical abuse (see
CHILD ABUSE and NON-ACCIDENTAL INJURY
Causes In Malta and the Mediterranean lit- (NAI)). Adults, too, may be subjected to regular
toral, the causative organism is the bacterium physical abuse.
Brucella melitensis which is conveyed in goats
milk. In Great Britain, the US and South Bruit and Murmur
Africa, the causative organism is the Brucella Abnormal sounds heard in connection with the
abortus, which is conveyed in cows milk: this is heart, arteries and veins on AUSCULTATION.
the organism which is responsible for con-
tagious abortion in cattle. In Great Britain bru- Bruxism
cellosis is largely an occupational disease and is Bruxism, or teeth-grinding, refers to a habit of
now prescribed as an industrial disease (see grinding the teeth, usually while asleep and
OCCUPATIONAL DISEASES), and insured persons without being aware of it. The teeth may feel
who contract the disease at work can claim uncomfortable on wakening. It is common in
industrial injuries benefit. The incidence of children and is usually of no significance. In
brucellosis in the UK has fallen from more than adults it may be associated with stress or a mal-
300 cases a year in 1970 to single figures. positioned or overfilled tooth. The underlying
 104 Bubo

cause should be treated but, if unsuccessful, a Bulla

plastic splint can be fitted over the teeth. An air- or fluid-filled bubble occurring in the
skin or lungs. The latter may be congenital or
B Bubo the result (in adults) of EMPHYSEMA. Skin bullae
(Plural: buboes.) A swelling of a lymphatic are really blisters.
gland in the groin in venereal disease (see SEXU-
ALLY TRANSMITTED DISEASES (STDS)) or in Bumetanide
PLAGUE. Bumetanide is a strong loop diuretic which is
active when taken by mouth. It acts quickly
Buccal within a half-hour and its action is over in a
Relating to the mouth or inside of the cheek. few hours. (See THIAZIDES; DIURETICS.)

Budgerigar-Fanciers Lung Bundle Branch Block

Budgerigar-fanciers lung is a form of extrinsic An abnormality of the conduction of electrical
allergic ALVEOLITIS, resulting from sensitisation impulses through the ventricles of the HEART,
to budgerigars, or parakeets as they are known resulting in delayed depolarisation of the ven-
in North America. Skin tests have revealed sen- tricular muscle. The electrocardiograph (see
sitisation to the birds droppings and/or serum. ELECTROCARDIOGRAM (ECG)) shows charac-
As it is estimated that budgerigars are kept in 5 teristic widening of the QRS complexes.
6 million homes in Britain, current figures sug- Abnormalities of the right and left bundle
gest that anything up to 900 per 100,000 of the branches cause delayed contraction of the right
population are exposed to the risk of developing and left ventricles respectively.
this condition.
Bundle of His
Buergers Disease Bundle of His, or atrioventricular bundle, is a
See THROMBOANGIITIS OBLITERANS. bundle of special muscle fibres which pass from
the atria to the ventricles of the HEART and
Bulbar Paralysis which form the pathway for the impulse which
See PARALYSIS; MOTOR NEURONE DISEASE (MND). makes the ventricles contract, the impulse ori-
ginating in the part of the atria known as the
Bulimia sinuatrial node.
Bulimia means insatiable appetite of psycho-
logical origin. This eating-disorder symptom Bunions
may be of psychological origin or the result of See CORNS AND BUNIONS.
neurological disease for example, a lesion of
the HYPOTHALAMUS. Bulimia nervosa is linked Bupivacaine
to anorexia nervosa and is sometimes called the A local anaesthetic, about four times as potent
binge and purge syndrome. Bulimia nervosa is as LIDOCAINE. It has a slow onset of action (up
characterised by overpowering urges to eat large to 30 minutes for full effect), but its effect lasts
amounts of food, followed by induced vomiting up to eight hours, making it particularly suit-
or abuse of laxatives to avoid any gain in able for continuous epidural analgesia in labour
weight. Most of the victims are prone to being (see PREGNANCY AND LABOUR). It is commonly
overweight and all have a morbid fear of obes- used for spinal anaesthesia, particularly lumbar
ity. They indulge in bouts of gross overeating, epidural blockade (see ANAESTHESIA). It is
or binge rounds as they describe them, to fill contraindicated in intravenous regional
the empty space inside. By their bizarre anaesthesia.
behaviour, most of them manage to maintain a
normal weight. The condition is most common Burkitts Lymphoma
in women in their 20s; it is accompanied by Malignant LYMPHOMA in children previously
irregular menstruation, often amounting to infected with EPSTEIN BARR VIRUS. It occurs
amenorrhoea (see MENSTRUATION). Although mainly in the jaw and abdominal organs. It is
there are many similarities to anorexia nervosa, common in parts of Africa where MALARIA is
bulimia nervosa differs in that there is no endemic.
attempt at deceit; sufferers freely admit to an
eating disorder and feel distress about the symp- Burning Feet
toms that it produces. In spite of this, the A SYNDROME characterised by a burning sensa-
response to treatment is, as in anorexia nervosa, tion in the soles of the feet. It is rare in temper-
far from satisfactory. (See EATING DISORDERS.) ate climes but widespread in India and the Far
 Burns and Scalds 105

East. The precise cause is not known, but it is regrowth of skin over the burned site; and deep
associated with malnutrition; lack of one or (or full-thickness) burns, when the skin is
more components of the vitamin B complex is totally destroyed and grafting will be necessary.
the likeliest cause (see APPENDIX 5: VITAMINS). B
Symptoms Whilst many domestic burns are
Burnout minor and insignificant, more severe burns and
A mental state of physical and emotional scalds can prove to be very dangerous to life.
exhaustion; an anxiety disorder that is a stress The main danger is due to SHOCK, which arises
reaction to a persons reduced capability to cope as a result of loss of fluid from the circulating
with the demands of his or her occupations. blood at the site of a serious burn. This loss of
Symptoms of burnout include tiredness, poor fluid leads to a fall in the volume of the circulat-
sleeping pattern, irritability and reduced per- ing blood. As the maintenance of an adequate
formance at work; increased susceptibility to blood volume is essential to life, the body
physical illness and abuse of alcohol and addict- attempts to compensate for this loss by with-
ive drugs can also occur. Treatment can be dif- drawing fluid from the uninjured areas of the
ficult and may require a change to a less stressful body into the circulation. If carried too far,
lifestyle, counselling and, in severe cases, psy- however, this in turn begins to affect the viabil-
chotherapy and carefully supervised use of ity of the body cells. As a sequel, essential body
ANXIOLYTICS or ANTIDEPRESSANT DRUGS. cells, such as those of the liver and kidneys,
begin to suffer, and the liver and kidneys cease
Burns and Scalds to function properly. This will show itself by
Burns are injuries caused by dry heat, scalds by the development of JAUNDICE and the appear-
moist heat, but the two are similar in symptoms ance of albumin in the urine (see PROTEINURIA).
and treatment. Severe burns are also caused by In addition, the circulation begins to fail with a
contact with electric wires, and by the action of resultant lack of oxygen (see ANOXIA) in the tis-
acids and other chemicals. The burn caused by sues, and the victim becomes cyanosed (see
chemicals differs from a burn by fire only in the CYANOSIS), restless and collapsed: in some cases,
fact that the outcome is more favourable, death ensues. In addition, there is a strong risk
because the chemical destroys the bacteria on of infection occurring. This is the case with
the affected part(s) so that less suppuration severe burns in particular, which leave a large
follows. raw surface exposed and very vulnerable to any
Severe and extensive burns are most fre- micro-organisms. The combination of shock
quently produced by the clothes for example, and infection can all too often be life-
of a child catching fire. This applies especially threatening unless expert treatment is immedi-
to cotton garments, which blaze up quickly. It ately available.
should be remembered that such a flame can The immediate outcome of a burn is largely
immediately be extinguished by making the determined by its extent. This is of more sig-
individual lie on the floor so that the flames are nificance than the depth of the burn. To assess
uppermost, and wrapping him or her in a rug, the extent of a burn in relation to the surface of
mat or blanket. As prevention is always better the body, what is known as the Rule of Nine has
than cure, particular care should always be exer- been evolved. The head and each arm cover 9
cised with electric fires and kettles or pots of per cent of the body surface, whilst the front of
boiling water in houses where there are young the body, the back of the body, and each leg
children or old people. Childrens clothes, and each cover 18 per cent, with the perineum (or
especially night-clothes, should be made of crutch) accounting for the remaining 1 per
non-inflammable material: pyjamas are also cent. The greater the extent of the burn, the
much safer than nightdresses. more seriously ill will the victim become from
Severe scalds are usually produced by escape loss of fluid from his or her circulation, and
of steam in boiler explosions. Cigarettes are a therefore the more prompt should be his or her
common cause of fires and therefore of burns; removal to hospital for expert treatment. The
people who have fallen asleep in bed or in a depth of the burn, unless this is very great, is
chair while smoking may set fire to the bed or mainly of import when the question arises as to
chair. Discarded, unextinguished cigarettes are how much surgical treatment, including skin
another cause. grafting, will be required.

Degrees of burns Burns are referred to as Treatment This depends upon the severity of
either superficial (or partial-thickness) burns, the burn. In the case of quite minor burns or
when there is sufficient skin tissue left to ensure scalds, all that may be necessary if they are seen
 106 Burr (Bur) Hole

immediately is to hold the part under cold run- and active rehabilitation programmes, offering
ning water until the pain is relieved. Cooling is victims a good chance of returning to normal
one of the most effective ways of relieving the life.
B pain of a burn. If the burn involves the distal
part of a limb for example, the hand and CHEMICAL BURNS Phenol or lysol can be washed
forearm one of the most effective ways of off promptly before they do much damage. Acid
relieving pain is to immerse the burned part in or alkali burns should be neutralised by washing
lukewarm water and add cold water until the them repeatedly with sodium bicarbonate or 1
pain disappears. As the water warms and pain per cent acetic acid, respectively. Alternatively,
returns, more cold water is added. After some the following buffer solution may be used for
three to four hours, pain will not reappear on either acid or alkali burns: monobasic potassium
warming, and the burn may be dressed in the phosphate (70 grams), dibasic sodium phos-
usual way. Thereafter a simple dressing (e.g. a phate (70 grams) in 850 millilitres of water. (See
piece of sterile gauze covered by cotton-wool, also PHOSPHORUS BURNS.)
and on top of this a bandage or adhesive dress-
ing) should be applied. The part should be kept Burr (Bur) Hole
at rest and the dressing kept quite dry until A circular hole made in the SKULL using a spe-
healing takes place. Blisters should be pierced cial surgical drill with a rounded tip, called the
with a sterile needle, but the skin should not be burr. The operation is done to relieve pressure
cut away. No ointment or oil should be applied, on the BRAIN. This pressure raised intracranial
and an antiseptic is not usually necessary. tension is commonly the result of blood col-
In slightly more severe burns or scalds, it is lecting between the skull and the brain after a
probably advisable to use some antiseptic dress- head injury. The presence of PUS or an increase
ing. These are the cases which should be taken in the amount of CEREBROSPINAL FLUID as a
to a doctor whether a general practitioner, a result of infection or tumours in the brain can
factory doctor, or to a hospital Accident & also cause a potentially fatal rise in intracranial
Emergency department. There is still no gen- pressure which can be relieved by drilling a burr
eral consensus of expert opinion as to the best hole. A neurosurgeon may make several burr
antiseptic to use. Among those recommended holes when doing a CRANIOTOMY, a procedure in
are CHLORHEXIDINE, and antibiotics such as which a section of the skull is removed to provide
BACITRACIN, NEOMYCIN and polymixin. An access to the brain and surrounding tissues.
alternative is to use a Tulle Gras dressing which Archaeological evidence suggests that modern
has been impregnated with a suitable antibiotic. mans ancestors used burr holes probably to treat
In the case of severe burns and scalds, the physical ailments and mental illness.
only sound rule is immediate removal to hos-
pital. Unless there is any need for immediate Bursae
resuscitation, such as artificial respiration, or Natural hollows in the fibrous tissues, lined by
attention to other injuries there may be, such as smooth cells and containing a little fluid. They
fractures or haemorrhage, nothing should be are situated at points where there is much pres-
done on the spot to the patient except to make sure or friction, and their purpose is to allow free
sure that s/he is as comfortable as possible and to movement without stretching or straining the
keep them warm, and to cover the burn with a tissues: for example, on the knee-cap or the point
sterile (or clean) cloth such as a sheet, pillow- of the elbow, and, generally speaking, where one
cases, or towels wrung out in cold water. If pain muscle rubs against another or against a bone.
is severe, morphine should be given usually They develop also beneath corns and bunions, or
intravenously. Once the victim is in hospital, where a bone presses on the skin.
the primary decision is as to the extent of the
burn, and whether or not a transfusion is neces- Bursitis
sary. If the burn is more than 9 per cent of the Inflammation within a bursa (see BURSAE).
body surface in extent, a transfusion is called Acute bursitis is usually the result of injury,
for. The precise treatment of the burn varies, especially on the knee or elbow, when the prom-
but the essential is to prevent infection if this inent part of the joint becomes swollen, hot,
has not already occurred, or, if it has, to bring it painful and red.
under control as quickly as possible. The treat- Chronic bursitis is due to too much move-
ment of severe burns has made great advances, ment of, or pressure on, a bursa, with fluid
with quick transport to specialised burns units, building up therein. Fluid may need to be
modern resuscitative measures, the use of skin drained and the affected area rested. Excision of
grafting and other artificial covering techniques a chronically inflamed bursa is sometimes
 Byte 107

necessary. For example, the condition of an artery (see ARTERIES), vein (see VEINS) or a
housemaids knee is a chronic inflammation of section of the gastrointestinal tract is bypassed
the patellar bursa in front of the knee, due to using surgery. Arterial blockages usually
too much kneeling. caused by ATHEROSCLEROSIS in the carotid, B
Chronic bursitis affecting ligaments round coronary or iliofemoral arteries are bypassed
the wrist and ankle is generally called a utilising sections of artery or vein taken from
GANGLION. elsewhere in the patient. Tumour growths in
the intestines are sometimes too large to
Buspirone remove and can be bypassed by linking up
A non-benzodiazepine drug used to treat anx- those parts of the intestines on each side of the
iety. It is believed to act at specific serotonin growth.
receptors of NEURON(E) cells. The patient may
take as long as two weeks to respond to Byssinosis
treatment. Chronic inflammatory thickening of the lung
tissue, due to the inhalation of dust in textile
Busulfan factories. It is found chiefly among cotton and
A drug used almost exclusively to treat chronic
flax workers and, to a lesser extent, among
myeloid LEUKAEMIA; it is given by mouth.
workers in soft hemp. It is rare or absent in
Excessive suppression of myelocytes may lead to
workers in jute and the hard fibres of hemp and
irreversible damage to BONE MARROW and
sisal. With much-improved working conditions
therefore to the manufacture of blood cells, so
in the UK, where byssinosis is one of the PRE-
frequent blood counts are necessary to check on
SCRIBED DISEASES, the disease is rare, but it is
the numbers of red and white cells.
still common in some Asian countries where
Butyrophenones textiles are manufactured.
Butyrophenones are a group of drugs, including
haloperidol, used to treat psychotic illness (see Byte
MENTAL ILLNESS). Computer terminology describing a group of
neighbouring bits, usually four, six or eight,
Bypass Operation working as a unit for the storage and manipula-
A technique by which narrowing or blockage of tion of data in a computer.
 proportion between the size of the fetal head

C and the maternal pelvis. The need for a Caesar-

ean should be assessed anew in each pregnancy;
a woman who has had a Caesarean section in
the past will not automatically need to have one
for subsequent deliveries. Caesarean-section
rates vary dramatically from hospital to hos-
Cachet pital, and especially between countries,
An oval capsule that encloses a dose of unpleas- emphasising that the criteria for operative
ant medicine. delivery are not universally agreed. The current
rate in the UK is about 23 per cent, and in the
Cachexia USA, about 28 per cent. The rate has shown a
Severe weight loss and listlessness produced by steady rise in all countries over the last decade.
serious disease such as cancer or tuberculosis, or Fear of litigation by patients is one reason for
by prolonged starvation. this rise, as is the uncertainty that can arise from
abnormalities seen on fetal monitoring during
Cadaver labour. Recent research suggesting that vaginal
A dead body. delivery is becoming more hazardous as the age
of motherhood rises may increase the pressure
Cadmium from women to have a Caesarean section as
A metallic element which, when molten, gives well as pressure from obstetricians.
off fumes that can cause serious irritation of the The operation is usually performed through
lungs if inhaled. a low, horizontal bikini line incision. A general
anaesthetic in a heavily pregnant woman carries
Cadmium Poisoning increased risks, so the operation is often per-
Cadmium poisoning is a recognised hazard in formed under regional epidural or spinal
certain industrial processes, such as the manu- ANAESTHESIA. This also allows the mother to see
facture of alloys, cadmium plating and glass her baby as soon as it is born, and the baby is not
blowing. Sewage sludge, which is used as fertil- exposed to agents used for general anaesthesia.
iser, may be contaminated by cadmium from If a general anaesthetic is needed (usually in an
industrial sources; such cadmium could be emergency), exposure to these agents may make
taken up into vegetable crops and cadmium the baby drowsy for some time afterwards.
levels in sewage are carefully monitored. Another problem with delivery by Caesarean
A tin-like metal, cadmium accumulates in section is, of course, that the mother must
the body. Long-term exposure can lead to recover from the operation whilst coping with
EMPHYSEMA, renal failure (see KIDNEYS, DIS- the demands of a small baby. (See PREGNANCY
EASES OF) and urinary-tract CALCULI. Acute AND LABOUR.)
exposure causes GASTROENTERITIS and PNEU-
MONITIS. Cadmium contamination of food is Caesium-137
the most likely source of poisoning. The EU An artificially produced radioactive element
Directive on the Quality of Water for Human that is used in RADIOTHERAPY treatment.
Consumption lays down 5 milligrams per litre
as the upper safe level. Caffeine
A white crystalline substance obtained from
Caecum coffee, of which it is the active principle. Its
The dilated first part of the large intestine lying main actions are as a cerebral stimulant, a car-
in the right lower corner of the abdomen.The diac stimulant, and a diuretic. It is a constituent
small intestine and the appendix open into it, of many tablets for the relief of headache, usu-
and it is continued upwards through the right ally combined with aspirin and paracetamol,
flank as the ascending colon. but its pain-killing properties are controversial.
One unusual use is in treating apnoeic attacks
Caesarean Section in premature babies (see APNOEA).
The operation used to deliver a baby through its
mothers abdominal wall. It is performed when Caisson Disease
the risks to mother or child of vaginal delivery See COMPRESSED AIR ILLNESS.
are thought to outweigh the problems associ-
ated with operative delivery. One of the most Calamine
common reasons for Caesarean section is dis- A mild astringent used, as calamine lotion, to
 Calcium Gluconate 109

soothe and protect the skin in many conditions CALCULI (stones) in the KIDNEYS or gall-
such as eczema and urticaria. bladder (see LIVER).
The recommended daily intakes of calcium
Calcaneus are: 500 mg for children, 700 mg for adoles-
The heel-bone or os calcis, and the largest bone cents, 500900 mg for adults and 1,200 mg for
in the foot. pregnant or nursing mothers. C
Calcicosis Calcium-Channel Blockers
Calcicosis is a traditional term applied to dis- Calcium-channel blockers inhibit the inward
ease of the lung caused by the inhalation of flow of calcium through the specialised slow
marble dust by marble-cutters. channels of cardiac and arterial smooth-muscle
cells. By thus relaxing the smooth muscle, they
Calciferol have important applications in the treatment of
HYPERTENSION and ANGINA PECTORIS. Various
This is an outdated term for ergocaliciferol or
vitamin D2 (see APPENDIX 5: VITAMINS). types of calcium-channel blockers are available
in the United Kingdom; these differ in their
sites of action, leading to notable differences in
Calcification their therapeutic effects. All the drugs are rap-
The deposition of CALCIUM salts in body tis- idly and completely absorbed, but extensive
sues, normally BONE and TEETH, though first-pass metabolism in the liver reduces bio-
abnormal deposits can occur in damaged availability to around one-fifth. Their hypo-
muscles or the walls of arteries. tensive effect is additive with that of beta
blockers (see BETA-ADRENOCEPTOR-BLOCKING
Calcinosis DRUGS); the two should, therefore, be used
Abnormal deposition of CALCIUM in the body together with great caution if at all. Calcium-
tissue. channel blockers are particularly useful when
beta blockers are contraindicated, for example
Calcitonin in asthmatics. However, they should be pre-
A hormone, produced by the THYROID GLAND, scribed for hypertension only when THIAZIDES
which is involved in the metabolism of bone. and beta blockers have failed, are contraindi-
Acting to lower concentrations of CALCIUM cated or not tolerated.
and PHOSPHATES in the blood, calcitonin is Verapamil, the longest-available, is used to
given by injection in the treatment of some treat angina and hypertension. It is the only
patients with HYPERCALCAEMIA (especially calcium-channel blocker effective against car-
when associated with malignant disease). In diac ARRHYTHMIA and it is the drug of choice
severe cases of PAGETS DISEASE OF BONE it is in terminating supraventricular tachycardia. It
used mainly for pain relief, but also relieves may precipitate heart failure, and cause HYPO-
some of the neurological complications such as TENSION at high doses. Nifedipine and
deafness. diltiazem act more on the vessels and less on the
myocardium than verapamil; they have no anti-
Calcium arrhythmic activity. They are used in the
The metallic element present in chalk and other prophylaxis and treatment of angina, and in
forms of lime. The chief preparations used in hypertension. Nicardipine and similar drugs act
medicine are calcium carbonate (chalk), cal- mainly on the vessels, but are valuable in the
cium chloride, calcium gluconate, calcium treatment of hypertension and angina. Import-
hydroxide (slaked lime), liquor of calcium ant differences exist between different calcium-
hydroxide (lime-water), calcium lactate, and channel blockers so their use must be carefully
calcium phosphate. Calcium gluconate is freely assessed. They should not be stopped suddenty,
soluble in water and is used in conditions in as this may precipitate angina. (See also HEART,
which calcium should be given by injection. DISEASES OF.)
Calcium is a most important element in diet;
the chief sources of it are milk and cheese. Cal- Calcium Gluconate
cium is especially needed by the growing child A salt of the element CALCIUM used to treat
and the pregnant and nursing mother. The deficiency of the mineral or to prevent osteo-
uptake of calcium by the baby is helped by porosis (see BONE, DISORDERS OF). Tablets can
vitamin D (see APPENDIX 5: VITAMINS). A be obtained without a doctors prescription. It
deficiency of calcium may cause TETANY, and is used intravenously to treat low calcium levels
an excess may result in the development of causing symptoms in newborn babies.
 110 Calculi

Calculi The large Calorie or kilocalorie, which is used

The general name given to concretions in, for in the study of dietetics and physiological pro-
example, the URINARY BLADDER, KIDNEYS or cesses, is the amount of heat required to raise
gall-bladder (see LIVER). one kilogram of water one degree centigrade in
temperature. The number of Calories required
C Caldicott Guardian to carry on the processes necessary for life and
A senior health professional in all NHS trusts, body warmth such as the beating of the heart,
whose responsibility it is to preserve the con- the movements of the chest in breathing, and
fidentiality of patient information. the chemical activities of the secreting glands
is, for an adult person of ordinary weight,
Calibre somewhere in the neighbourhood of 1,600. For
A talking-book service which is available to all ordinary sedentary occupations an individual
blind and handicapped people who can supply requires about 2,500 Calories; for light muscu-
a doctors certificate confirming that they are lar work slightly over 3,000 Calories; and for
unable to read printed books in the normal way. hard continuous labour around 4,000 Calories
Its catalogue contains more than 370 books for daily.
adults and more than 250 for children, and Under the International System of Units (SI
UNITS see APPENDIX 6: MEASUREMENTS IN
additions are being made at the rate of around
MEDICINE) the kilocalorie has been replaced by
three a week. Full details can be obtained from
Calibre. the joule, the abbreviation for which is J (1
www.calibre.org.uk kilocalorie=4,1868 J). The term Calorie, how-
ever, is so well established that it has been
retained in this edition. Conversion from
Calliper Calories (or kilocalories) to joules is made by
A two-pronged instrument with pointed ends,
multiplying by 42 .
for the measurement of diameters, such as that
of the pelvis in obstetrics.
Calyx
Calyx means a cup-shaped cavity, the term
Calliper Splint being especially applied to the recesses of the
This is applied to a broken leg in such a way pelvis of the kidney.
that in walking, the weight of the body is taken
by the hip-bone and not by the foot. CAM
See COMPLEMENTARY AND ALTERNATIVE MEDI-
Callosities CINE (CAM).
Areas of gross thickening of the epidermis in
response to trauma. They usually occur on a Campylobacter
foot due to bony deformity or ill-fitting foot- A species of bacterium found in farm and pet
wear. (See CORNS AND BUNIONS.) animals, from which it can be transmitted to
humans, in whom it is a major cause of bac-
Callus terial FOOD POISONING: outbreaks of infection
The new tissue formed around the ends of a have followed drinking unpasteurised milk
broken bone. (See BONE, DISORDERS OF.) from infected cows and eating undercooked
meat and poultry. It causes diarrhoea.
Caloric Test In the United Kingdom, the number of
A test for vestibular function (see EAR). It is per- cases of food poisoning (by all types of infec-
formed by irrigating the external auditory tion) has risen from 102.9 to 162.9 per
meatus of the ear with alternate cold and hot 100,000 population over the last 15 years. In
water. This usually stimulates the vestibular 2003, more then 70,000 cases of food poison-
apparatus, causing nystagmus (see DIABETES ing were notified. The use of preventive
MELLITUS Diabetic eye disease). If the ves- methods throughout the food production pro-
tibular apparatus is affected by disease, the cess, marketing and consumption of food is
response may be absent or reduced. most important in controlling infection, as is
taking hygienic precautions, such as hand-
Calorie washing, after handling animals including
A unit of energy. Two units are called by this domestic pets.
name. The small calorie, or gram calorie, is the Mild cases can be treated at home with no
amount of heat required to raise one gram of solid food but plenty of liquids and some salt.
water one degree centigrade in temperature. Serious cases require hospital care.
 Cancer 111

Canaliculus malignant disease. There is wide international

Canaliculus means a small channel, and is variation in the most frequently encountered
applied to (a) the minute passage leading from types of cancer, reflecting the importance of
the lacrimal pore on each eyelid to the lacrimal environmental factors in the development of
sac on the side of the nose; (b) any one of the cancer. In the UK as well as the US, carcinoma
minute canals in bone. of the BRONCHUS is the most common. Since it C
is usually inoperable at the time of diagnosis, it
Cancellous is even more strikingly the leading cause of can-
A term applied to loose bony tissues as found in cer deaths. In women, breast cancer was for a
the ends of the long bones. long time the most common malignant disease,
accounting for a quarter of all cancers, but fig-
Cancer ures for the late 1990s show that lung cancer
The general term used to refer to a malignant now heads the incidence list presumably the
TUMOUR, irrespective of the tissue of origin. consequence of a rising incidence of smoking
Malignancy indicates that (i) the tumour is among young women. Other common sites are
capable of progressive growth, unrestrained by as follows: males colon and rectum, prostate
the capsule of the parent organ, and/or (ii) that and bladder; females colon and rectum,
it is capable of distant spread via lymphatics or uterus, ovary and pancreas.
the bloodstream, resulting in development of In 2003, of the more than 154,000 people in
secondary deposits of tumour known as metas- the UK who died of cancer, over 33,000 had
tases. Microscopically, cancer cells appear dif- the disease in their respiratory system, nearly
ferent from the equivalent normal cells in the 13,000 in the breast, over 5,800 in the stomach
affected tissue. In particular they may show a and more than 2,000 in the uterus or cervix,
lesser degree of differentiation (i.e. they are while over 4,000 people had leukaemia. The
more primitive), features indicative of a faster incidence of cancer varies with age; the older a
proliferative rate and disorganised alignment in person is, the more likely it is that he or she will
relationship to other cells or blood vessels. The develop the disease. The over-85s have an inci-
diagnosis of cancer usually depends upon the dence about nine times greater than those in the
observation of these microscopic features in 2544 age group. There are also differences in
biopsies, i.e. tissue removed surgically for such incidence between sexes: for example, more
examination. men than women develop lung cancer, though
Cancers are classified according to the type the incidence in women is rising as the effects of
of cell from which they are derived as well as smoking work through. The death rate from
the organ of origin. Hence cancers arising cancer is falling in people under 75 in the UK, a
within the bronchi, often collectively referred trend largely determined by the cancers which
to as lung cancer, include both adenocarci- cause the most deaths: lung, breast, colorectal,
nomas, derived from epithelium (surface tis- stomach and prostate.
sue), and carcinomas from glandular tissue.
Sarcomas are cancers of connective tissue, Causes In most cases the causes of cancer
including bone and cartilage. The behaviour remain unknown, though a family history of
of cancers and their response to therapy vary cancer may be relevant. Rapid advances have,
widely depending on this classification as well however, been made in the past two decades in
as on numerous other factors such as how understanding the differences between cancer
large the cancer is, how fast the cells grow and cells and normal cells at the genetic level. It is
how well defined they are. It is entirely wrong now widely accepted that cancer results from
to see cancer as a single disease entity with a acquired changes in the genetic make-up of a
universally poor prognosis. For example, fewer particular cell or group of cells which ultimately
than one-half of women in whom breast can- lead to a failure of the normal mechanisms regu-
cer (see BREASTS, DISEASES OF) is discovered lating their growth. It appears that in most cases
will die from the disease, and 75 per cent of a cascade of changes is required for cells to
children with lymphoblastic LEUKAEMIA can behave in a truly malignant fashion; the critical
be cured. changes affect specific key GENES, known as
oncogenes, which are involved in growth
Incidence In most western countries, cancer regulation. (See APOPTOSIS.)
is the second most important cause of death Since small genetic errors occur within cells
after heart disease and accounts for 2025 per at all times most but not all of which are
cent of all deaths. In the United Kingdom in repaired it follows that some cancers may
2003, more than 154,000 people died of develop as a result of an accumulation of
 112 Cancrum Oris

random changes which cannot be attributed to idly growing tumours composed of primitive
environmental or other causes. The environ- cells which are much more vulnerable to the
mental factors known to cause cancer, such as toxic effects of the chemotherapeutic agents
radiation and chemicals (including tar from than the normal cells within the body.
tobacco, asbestos, etc.), do so by increasing the Unfortunately neither radiotherapy nor cur-
C overall rate of acquired genetic damage. Certain rently available chemotherapy provides a cura-
viral infections can induce specific cancers (e.g. tive option for the majority of common cancers
HEPATITIS B VIRUS and HEPATOMA, EPSTEIN if surgical excision is not feasible. New effective
BARR VIRUS and LYMPHOMA) probably by treatments in these conditions are urgently
inducing alterations in specific genes. HOR- needed. Nevertheless the rapidly increasing
MONES may also be a factor in the development knowledge of cancer biology will almost cer-
of certain cancers such as those of the prostate tainly lead to novel therapeutic approaches
and breast. Where there is a particular family including probably genetic techniques utilising
tendency to certain types of cancer, it now the recent discoveries of oncogenes (genes that
appears that one or more of the critical genetic can cause cancer). Where cure is not possible,
abnormalities required for development of that there often remains much that can be done for
cancer may have been inherited. Where the cancer-sufferer in terms of control of
environmental factors such as tobacco smoking unpleasant symptoms such as pain. Many of the
or asbestos are known to cause cancer, then most important recent advances in cancer care
health education and preventive measures can relate to such palliative treatment, and include
reduce the incidence of the relevant cancer. the establishment in the UK of palliative care
Cancer can also affect the white cells in the hospices.
blood and is called LEUKAEMIA. Families and patients can obtain valuable
help and advice from Marie Curie Cancer Care,
Treatment Many cancers can be cured by Cancer Relief Macmillan Fund, or the British
surgical removal if they are detected early, Association of Cancer United Patients.
before there has been spread of significant www.cancerbacup.org.uk
numbers of tumour cells to distant sites. www.mariecurie.org.uk
Important within this group are breast, colon
and skin cancer (melanoma). The probability of Cancrum Oris
early detection of certain cancers can be Cancrum oris, also called noma, is a gangren-
increased by screening programmes in which ous ulcer about the mouth which affects sickly
(ideally) all people at particular risk of devel- children, especially after some severe disease
opment of such cancers are examined at regular such as measles. It is due to the growth of
intervals. Routine screening for CERVICAL CAN- bacteria in the tissues.
CER and breast cancer (see BREASTS, DISEASES
OF) is currently practised in the UK. The Candida
effectiveness of screening people for cancer is, Candidosis (moniliasis) is an infection with the
however, controversial. Apart from questions yeast, Candida albicans. It is encouraged by
surrounding the reliability of screening tests, pregnancy, DIABETES MELLITUS, prolonged
they undoubtedly create anxieties among the wide-spectrum ANTIBIOTICS or CORTICO-
subjects being screened. STEROIDS therapy, and is also seen in debilitated
If complete surgical removal of the tumour is infants, the elderly and immunocompromised
not possible because of its location or because patients, e.g. those with AIDS/HIV. It may cause
spread from the primary site has occurred, an white patches in the mouth or vulvovaginal area
operation may nevertheless be helpful to relieve (thrush) and a red vesicular and scaly rash in the
symptoms (e.g. pain) and to reduce the bulk of finger clefts, beneath the breasts or in the groin
the tumour remaining to be dealt with by alter- or anogenital folds. Fingernail-fold infection
native means such as RADIOTHERAPY or causes chronic PARONYCHIA with secondary nail
CHEMOTHERAPY. In some cases radiotherapy is DYSTROPHY and may complicate RAYNAUDS
preferable to surgery and may be curative, for DISEASE. CLOTRIMAZOLE and similar azoles as
example, in the management of tumours of the creams, oral gels or vaginal pessaries are rapidly
larynx or of the uterine cervix. Certain tumours effective, but severe systemic infections require
are highly sensitive to chemotherapy and may oral itraconazole or even intravenous AMPHO-
be cured by the use of chemotherapeutic drugs TERICIN B.
alone. These include testicular tumours, LEU-
KAEMIA, LYMPHOMA and a variety of tumours Canine Teeth
occurring in childhood. These tend to be rap- Or eye-teeth see TEETH.
 Carbachol 113

Cannabis through the tissues of the body, bathing the lat-

Psychoactive substances obtained from Canna- ter in blood with only the thin capillary wall
bis sativa or Indian hemp, they are the oldest interposed, through which gases and fluids
euphoriants. Also called marijuana, these sub- readily pass. These vessels are less than 0025
stances do not usually result in physical mm in width.
DEPENDENCE but chronic abuse leads to passiv- C
ity, apathy and inertia. Acute adverse effects Capillary Return
include transient panic reactions and toxic A test for the adequacy of blood circulation by
psychoses. The panic reactions are characterised pressing on the skin and seeing how long it
by anxiety, helplessness and loss of control and takes for the colour to return. (See
may be accompanied by florid paranoid PERFUSION.)
thoughts and hallucinations. The toxic psych-
oses are characterised by the sudden onset of Capsule
confusion and visual hallucinations. Even at A term used in several senses in medicine. It is
lower doses, cannabis products can precipitate applied to a soluble case, usually of gelatine, for
functional psychoses in vulnerable individuals. enclosing small doses of unpleasant medicine.
The acute physical manifestations of short-term Enteric-coated capsules, which have been
cannabis abuse are conjunctival suffusion and largely superseded by enteric-coated tablets, are
tachycardia. capsules treated in such a manner that the
The chopped leaves are usually smoked but ingredients do not come in contact with the
can be eaten in food or taken as tea. The active acid stomach contents but are only released
ingredient is tetrahydrocannibol. There is much when the capsule disintegrates in the alkaline
public debate in western countries over the contents of the intestine.
social use of cannabis: it is illegal to possess or The term is also applied to the fibrous or
supply the substance in the United Kingdom, membranous envelope of various organs, as of
but nevertheless cannabis is quite widely used. the spleen, liver or kidney. Additionally, it is
Cannabis is classified as a Schedule 1 drug applied to the ligamentous bag surrounding
under the Misuse of Drugs Act 1971 and has various joints and attached by its edge to the
not officially been used medicinally despite bones on either side.
some claims that it is helpful in ameliorating
painful symptoms in certain serious chronic Captopril
diseases such as multiple sclerosis. A related An ACE-inhibitor drug introduced for the
agent, NABILONE, is a synthetic cannabinoid treatment of patients with severe HYPERTEN-
licenced for use in treating nausea and vomiting SION. It acts by lowering the concentration in
caused by CYTOTOXIC drugs. the blood of angiotensin II which is one of the
factors responsible for high blood pressure. (See
Cannula ANGIOTENSIN; RENIN.)
A tube for insertion into the body, designed to
fit tightly round a trocar a sharp, pointed Caput Medusae (Medusas
instrument which is withdrawn from the can- Head)
nula after insertion, so that fluid may run out The term describing the abnormally dilated
through the latter. veins that form around the umbilicus in CIR-
RHOSIS of the liver.
Canthus
The name applied to the angle at either end of Caput Succedaneum
the aperture between the eyelids. Usually shortened by obstetricians to caput,
this is the temporary swelling which is some-
CAPD times found on the head of the newborn infant.
Chronic ambulatory peritoneal dialysis an It is due to OEDEMA in and around the scalp,
outpatient technique for treating failure of the caused by pressure on the head as the child is
KIDNEYS. (See HAEMODIALYSIS.) born. It is of no significance and quickly disap-
pears spontaneously.
Capillaries
The minute vessels which join the ends of the Carbachol
arteries to venules, the tiny commencement of A drug which stimulates the parasympathetic
veins. Their walls consist of a single layer of nervous system, for example, for relieving
fine, flat, transparent cells, bound together at GLAUCOMA and retention of urine due to
the edges, and the vessels form a meshwork all ATONY.
 114 Carbamazepine

Carbamazepine Carbon
An anticonvulsant drug used to treat most A non-metallic element, the compounds of
types of EPILEPSY, including simple and com- which are found in all living tissues and which
plex partial seizures and tonic-clonic seizures is a constituent (as carbon dioxide) of air
secondary to a focal discharge. Monitoring of exhaled from the LUNGS. Two isotopes of
C concentrations in the blood may be of help in carbon, 11C and 14C, are used in medicine.
finding the most effective dose. Carbamazepine Carbon-11 is used in positron-emission tom-
has generally fewer side-effects than other ography (see PET SCANNING); carbon-14 is used
antiepileptic drugs; even so, it should be started as a tracer element in studying various aspects
at a low dose and increased incrementally. The of METABOLISM.
drug is also used to treat TRIGEMINAL NEUR-
ALGIA and other types of nerve pain, as well Carbon Dioxide (CO2)
as pain from a PHANTOM LIMB. DEPRESSION Formed by the body during metabolism and
resistant to LITHIUM CARBONATE may also exhaled by the lungs. Seen in sparkling waters
benefit from carbamazepine. and wines, it is also used in baths as a stimulant
to the skin. Combined with oxygen in cylin-
Carbaryl ders, it is used to control breathing in ANAES-
A pesticide used to kill head and crab lice (see THESIA and in the treatment of victims of CAR-
PEDICULOSIS). Available as a lotion, some of BON MONOXIDE (CO) poisoning.
which contains alcohol (not recommended for Measuring the partial pressure of the gas by
use on crab lice), the substance may irritate skin taking blood for blood gas estimation provides
and should not be used near damaged skin, eyes information on the adequacy of breathing. A
or ears. high partial pressure may indicate impending or
actual respiratory failure.
Carbimazole
One of the most widely used drugs in the Carbonic Anhydrase Inhibitor
treatment of HYPERTHYROIDISM. It acts by A drug that curbs the action of an ENZYME in
interferring with the synthesis of thyroid the blood controlling the production of car-
hormone in the thyroid gland. bonic acid or bicarbonate from CARBON
DIOXIDE (CO2). Called carbonic anhydrase, the
Carbohydrate enzyme is present in ERYTHROCYTES and it has
The term applied to an organic substance in a key part in maintaining the acid-base balance
which the hydrogen and oxygen are usually in in the blood. Inhibiting drugs include ACETA-
the proportion to form water. Carbohydrates ZOLAMIDE and DORZOLAMIDE, and these are
are all, chemically considered, derivatives of used as weak DIURETICS to reduce the increased
simple forms of sugar and are classified as intraocular pressure in ocular hypertension or
monosaccharides (e.g. glucose), disaccharides open-angle GLAUCOMA (see EYE, DISORDERS
(e.g. cane sugar), polysaccharides (e.g. starch). OF).
Many of the cheaper and most important foods
are included in this group, which comprises Carbon Monoxide (CO)
sugars, starches, celluloses and gums. When one This is a colourless, odourless, tasteless, non-
of these foods is digested, it is converted into a irritating gas formed on incomplete combus-
simple kind of sugar and absorbed in this form. tion of organic fuels. Exposure to CO is fre-
Excess carbohydrates, not immediately needed quently due to defective gas, oil or solid-fuel
by the body, are stored as glycogen in the liver heating appliances. CO is a component of car
and muscles. In DIABETES MELLITUS, the most exhaust fumes and deliberate exposure to these
marked feature consists of an inability on the is a common method of suicide. Victims of fires
part of the tissues to assimilate and utilise the often suffer from CO poisoning. CO combines
carbohydrate material. Each gram of carbo- reversibly with oxygen-carrying sites of
hydrate is capable of furnishing slightly over 4 HAEMOGLOBIN (Hb) molecules with an affinity
Calories of energy. (See CALORIE; DIET.) 200 to 300 times greater than oxygen itself. The
carboxyhaemoglobin (COHb) formed becomes
Carbolic Acid unavailable for oxygen transportation. In add-
Carbolic acid, or phenol, was the precursor of ition the partial saturation of the Hb molecule
all ANTISEPTICS. It paralyses and then destroys results in tighter oxygen binding, impairing
most forms of life, particularly organisms delivery to the tissues. CO also binds to MYO-
such as bacteria. It has been superseded by less GLOBIN and respiratory cytochrome enzymes.
penetrative and harmful antiseptics. Exposure to CO at levels of 500 parts per mil-
 Carcinomatosis 115

lion (ppm) would be expected to cause mild airway and give 100-per-cent oxygen by tight-
symptoms only and exposure to levels of 4,000 fitting mask. In hospital, management is largely
ppm would be rapidly fatal. suppportive, with oxygen administration. A
Each year around 50 people in the United blood sample for COHb level determination
Kingdom are reported as dying from carbon should be taken as soon as practicable and, if
monoxide poisoning, and experts have sug- possible, before oxygen is given. Ideally, oxygen C
gested that as many as 25,000 people a year are therapy should continue until the COHb level
exposed to its effects within the home, but falls below 5 per cent. Patients with any history
most cases are unrecognised, unreported and of unconsciousness, a COHb level greater than
untreated, even though victims may suffer from 20 per cent on arrival, any neurological signs,
long-term effects. This is regrettable, given that any cardiac arrhythmias or anyone who is preg-
Napoleons surgeon, Larrey, recognised in the nant should be referred for an expert opinion
18th century that soldiers were being poisoned about possible treatment with hyperbaric oxy-
by carbon monoxide when billeted in huts gen, though this remains a controversial ther-
heated by woodburning stoves. In the USA it is apy. Hyperbaric oxygen therapy shortens the
estimated that 40,000 people a year attend half-life of COHb, increases plasma oxygen
emergency departments suffering from carbon transport and reverses the clinical effects result-
monoxide poisoning. So prevention is clearly an ing from acute exposures. Carbon monoxide is
important element in dealing with what is also an environmental poison and a component
sometimes termed the silent killer. Safer of cigarette smoke. Normal body COHb levels
designs of houses and heating systems, as well as due to ENDOGENOUS CO production are 0.4 to
wider public education on the dangers of car- 0.7 per cent. Non-smokers in urban areas may
bon monoxide and its sources, are important. have level of 12 per cent as a result of
Clinical effects of acute exposure resemble environmental exposure. Smokers may have a
those of atmospheric HYPOXIA. Tissues and COHb level of 5 to 6 per cent.
organs with high oxygen consumption are
affected to a great extent. Common effects Carboxyhaemoglobinaemia
include headaches, weakness, fatigue, flush- The term applied to the state of the blood in
ing, nausea, vomiting, irritability, dizziness, carbon monoxide poisoning, in which this gas
drowsiness, disorientation, incoordination, vis- combines with the haemoglobin, displacing
ual disturbances, TACHYCARDIA and HYPER- oxygen from it. (See CARBON MONOXIDE (CO).)
VENTILATION. In severe cases drowsiness may
progress rapidly to COMA. There may also be Carbuncle
metabolic ACIDOSIS, HYPOKALAEMIA, CONVUL- See BOILS (FURUNCULOSIS).
SIONS, HYPOTENSION, respiratory depression,
ECG changes and cardiovascular collapse. Cere- Carcinogenesis
bral OEDEMA is common and will lead to severe Carcinogenesis is the means or method
brain damage and focal neurological signs. whereby the changes responsible for the induc-
Significant abnormalities on physical examin- tion of CANCER are brought about.
ation include impaired short-term memory,
abnormal Rhombergs test (standing unsup- Carcinogens
ported with eyes closed) and unsteadiness of Agents, such as tobacco smoke, certain chem-
gait including heel-toe walking. Any one of icals, asbestos fibres and high-dose radiation,
these signs would classify the episode as severe. that have the property of causing CANCER.
Victims skin may be coloured pink, though
this is very rarely seen even in severe incidents. Carcinoma
The venous blood may look arterial. Patients A type of CANCER developing from cells found
recovering from acute CO poisoning may suffer in the surface layer of an organ in the body.
neurological sequelae including TREMOR, per-
sonality changes, memory impairment, visual Carcinoma in Situ
loss, inability to concentrate and PARKINSON- The first stage of CARCINOMA in which the
ISM. Chronic low-level exposures may result in malignant tumour is present only in the EPI-
nausea, fatigue, headache, confusion, VOMIT- THELIUM, and when surgical excision of the
ING, DIARRHOEA, abdominal pain and general local growth, with its pathological status con-
malaise. They are often misdiagnosed as influ- firmed in the laboratory, should ensure a cure.
enza or food poisoning.
First-aid treatment is to remove the victim Carcinomatosis
from the source of exposure, ensure an effective The spread of cancer cells from their original
 116 Cardia

site of growth to other tissues in the body. Such cardial infarction, but also present in some
a spread of cancer, which takes place mainly via normal individuals especially if they have
blood and lymph vessels, is usually fatal. taken a lot of coffee or other stimulant and in
CHEMOTHERAPY and RADIOTHERAPY may, those with a congenital abnormality of the
however, check the spread or sometimes destroy heart-muscle conducting system. The cause is
C the cancerous growth. interference in the generation or transmission
of electrical impulses through the hearts con-
Cardia ducting system. Occasional isolated irregular
Cardia is a term applied to the upper opening beats (ectopic beats) do not necessarily mean
of the stomach into which the oesophagus emp- that conduction is faulty. Arrhythmias can be
ties. The cardia lies immediately behind the classified as tachycardias (more than 100 beats a
heart. minute) or bradycardias (slower than 60 beats a
minute). Heartbeats may be regular or irregular.
Cardiac Arrest (See HEART, DISEASES OF.)
Cardiac arrest occurs when the pumping action
of the heart stops. This may be because the Cardiac Catheterisation
heart stops beating (see ASYSTOLE) or because A diagnostic procedure in which a tube is
the heart muscle starts contracting too fast to inserted into a blood vessel under local anaes-
pump effectively (ventricular systole, the period thetic and threaded through to the chambers of
when the heart contracts). Coronary throm- the heart to monitor blood flow, blood pressure,
bosis is the most frequent cause of arrest. blood chemistry and the output of the heart,
Irreversible brain damage and death result and to take a sample of heart tissue. The tech-
without prompt treatment. Heart massage, nique is used to diagnose congenital heart dis-
defibrillation and artificial respiration are cus- ease and coronary artery disease. Another appli-
tomary treatment. Other causes of cardiac cation is in the diagnosis and treatment of
arrest are respiratory arrest, anaphylactic shock valvular disease in the heart.
and electrocution. Up to one-third of patients
treated in hospital whose heart rhythm is Cardiac Cycle
restored recover to an extent that enables them The various sequential movements of the heart
to return home. (See APPENDIX 1: BASIC FIRST that comprise the rhythmic relaxation and
AID Cardiac/respiratory arrest.) expansion of the heart muscles as first the atria
contract and force the blood into the ventricles
Cardiac Arrhythmia (diastole), which then contract (systole) to
Abnormal rhythm of the heartbeat. Most pump the blood round the body. (See
commonly seen after someone has had a myo- ELECTROCARDIOGRAM (ECG).)

Catheterisation of coronary artery, a diagnostic procedure to determine patency of the artery.

 Cardiology 117

Cardiac Disease by the ventricles of the heart. It is one measure

See HEART, DISEASES OF. of the hearts efficiency. At rest, the heart of a
healthy adult will pump between 2.5 and 4.5
Cardiac Glycosides litres of blood every minute. Exercise will raise
Drugs whose main actions are to increase the this to as much as 30 litres a minute but, if this
force of myocardial contraction and reduce the figure is low, it suggests that the heart muscle C
conductivity of the nerve fibres in the atrioven- may be diseased or that the person has suffered
tricular node of the heart. They are useful in severe blood loss.
treating supraventricular tachycardias (rapid
heart rhythm) and some forms of heart failure. Cardiac Pacemaker
Glycosides are a traditional group of cardiac The natural pacemaker is the sinuatrial node,
drugs, originally derived from the leaves of fox- found at the base of the heart. The heart nor-
glove plants and used as digitalis. The active mally controls its rate and rhythm; heart block
principle has long been synthesised and used as occurs when impulses cannot reach all parts of
DIGOXIN. They are potentaially toxic and their the heart. This may lead to ARRHYTHMIA, or
use, especially during initial treatment, should even cause the heart to stop (see HEART, DIS-
be monitored. Side-effects include ANOREXIA, EASES OF). Artificial pacemakers may then be
nausea, vomiting, diarrhoea and abdominal used; in the United Kingdom these are required
pain; drowsiness, confusion and DEPRESSION for around one person in every 2,000 of the
may occur. An abnormally slow heart rate may population. Usually powered by mercury or
develop. The glycosides should be used with lithium batteries, and lasting up to 15 years,
special care in the elderly who are sometimes they are either fixed to the outside of the chest
particularly susceptible to their toxic effects. or implanted in the armpit, and connected by a
wire passing through a vein in the neck to the
Cardiac Massage heart. Normally adjusted to deliver 6575
The procedure used to restart the action of the impulses a minute, they also ensure a regular car-
heart if it is suddenly arrested. In many cases diac rhythm. Patients with pacemakers may be
the arrested heart can be made to start beating given a driving licence provided that their vehicle
again by rhythmic compression of the chest is not likely to be a source of danger to the public,
wall. This is done by placing the patient on a and that they are receiving adequate and regular
hard surface a table or the floor and then medical supervision from a cardiologist.
placing the heel of the hand over the lower part Although there are numerous possible
of the sternum and compressing the chest wall sources of electrical interference with pace-
firmly, but not too forcibly, at the rate of 6080 makers, the overall risks are slight. Potential
times a minute. At the same time artificial res- sources include anti-theft devices, airport
piration must be started by the mouth-to- weapon detectors, surgical diathermy, ultra-
mouth method. (See APPENDIX 1: BASIC FIRST sound, and short-wave heat treatment. Never-
AID.) Open heart massage is sometimes under- theless, many pacemaker patients lead active
taken if an arrest occurs during a chest oper- and fulfilling lives.
ation the heart being directly handled by the
resuscitator. Cardiac Pump
See HEART, ARTIFICIAL.
Cardiac Muscle
The muscle, unique to the heart, which com- Cardiac Tamponade
prises the walls of the atria and ventricles. It Compression of the heart due to abnormal
consists of long broadening cells (fibres) with accumulation of fluid within the fibrous cover-
special physiological characteristics which ing of the heart (PERICARDIUM). The result is
enable them to keep contracting and expanding irregular rhythm and death if the fluid is not
indefinitely. removed.

Cardiac Neurosis Cardioangiography

Obsessional fear about the state of the heart. It Rendering the outline of the heart visible on an
tends to occur after a heart attack and may X-ray film by injecting a radio-opaque sub-
result in the patients experiencing the symp- stance into it.
toms of another attack.
Cardiology
Cardiac Output That branch of medical science devoted to the
The volume of blood pumped out per minute study of the diseases of the heart.
 118 Cardiomegaly

Cardiomegaly circulates throughout the cardiovascular system

Enlargement of the heart (see HEART, DISEASES bringing oxygen and nutrients to the tissues
OF). and removing carbon dioxide and other waste
products.
Cardiomyopathy
C A general term covering primary disease of the Cardioversion
heart muscle. (See HEART, DISEASES OF.) Cardioversion, or DEFIBRILLATION, is indi-
cated in patients with ventricular fibrillation
Cardioplegia or tachycardia, fast or irregular heartbeat, if
A procedure whereby the heart is stopped by other treatments have failed. A general anaes-
reducing its temperature (hypothermia), by thetic is given if the patient is conscious, fol-
injecting the muscle with a solution of salts or lowing which a carefully timed direct-current
by electrostimulation. This enables surgeons to shock is applied to the patients chest wall
operate safely on the heart. using a DEFIBRILLATOR. The patients ECG
rhythm should then be monitored and anti-
Cardiopulmonary Bypass coagulants considered, as the risk of EMBOLISM
A procedure in which the bodys circulation of is increased.
blood is kept going when the heart is intention-
ally stopped to enable heart surgery to be car- Care in Community
ried out. A HEART-LUNG MACHINE substitutes See COMMUNITY CARE.
for the hearts pumping action and the blood is
oxygenated at the same time. Care Standards Act
Legislation (approved by the UK parliament in
Cardiopulmonary Resuscitation 2001) that sets up a new, independent regula-
(CPR) tory body for social care and private and volun-
The use of life-saving measures of mouth-to- tary health-care services. The new body is called
mouth resuscitation and external cardiac com- the National Care Standards Commission and
pression massage in a person who has collapsed covers England and Wales, but in the latter the
with CARDIAC ARREST. Speedy restoration of National Assembly is the regulatory body.
the circulation of oxygenated blood to the brain Independent councils register social-care work-
is essential to prevent damage to brain tissues ers, set social-care work standards and regulate
from oxygen starvation. The brain is irrevers- the education and training of social workers in
ibly damaged if it is starved of oxygen for more England and Wales. The Act also gives the Sec-
than 45 minutes. Someone whose heart has retary of State for Health the authority to keep a
stopped will be very pale or blue-grey (in par- list of individuals considered unsuitable to work
ticular, round the lips) and unresponsive; he or with vulnerable adults. In addition, the legisla-
she will not be breathing and will have no pulse. tion reforms the regulation of childminders and
It is important to determine that the collapsed day-care provision for young children,
person has not simply fainted before starting responsibility for overseeing these services hav-
CPR. The procedure is described under car- ing been transferred from local authorities to
diac/respiratory arrest in APPENDIX 1: BASIC the Chief Inspector of Schools. Services covered
FIRST AID. In hospital, or when paramedical by the Act range from residential care homes
staff are attending an emergency, CPR may and nursing homes, childrens homes,
include the use of a DEFIBRILLATOR to apply a domiciliary-care agencies, fostering agencies
controlled electric shock to the heart via the and voluntary adoption agencies through to
chest wall. private and voluntary health-care services. This
includes private hospitals and clinics and pri-
Cardiospasm vate primary-care premises. For the first time,
The spasmodic contraction of the muscle sur- local authorities will have to meet the same
rounding the opening of the oesophagus into standards as independent-sector providers.
the stomach: also termed achalasia of the cardia.
(See OESOPHAGUS, DISEASES OF.) Caries
See TEETH, DISORDERS OF.
Cardiovascular System
This refers to the whole circulatory system: the Carminatives
heart, the systemic circulation (the arteries and Preparations to relieve FLATULENCE, and any
veins of the body) and the pulmonary circula- resulting griping, by the bringing up of wind,
tion (the arteries and veins of the lungs). Blood or ERUCTATION. Their essential constituent is
 Castration 119

an aromatic volatile oil, usually of vegetable forms a joint with other bones (articular cartil-
extraction. age), and in young persons up to about the age
of 16 there is a plate of cartilage (epiphyseal
Carneous Mole cartilage) running right across the bone about
An ovum which has died in the early months of 12 mm (half an inch) from each end. The latter,
pregnancy. It usually requires no treatment and by constantly thickening and changing into C
evacuates itself. bone, causes the increase in length of the bone.
(See also BONE.) In some situations there is found
Carotene a combination of cartilage and fibrous tissue, as
A colouring matter of carrots, other plants, but- in the discs between the vertebrae of the spine.
ter and yolk of egg, carotene is the precursor of This fibro-cartilage, as it is known, combines
vitamin A, which is formed from carotene in the pliability of fibrous tissue with the elasticity
the liver. (See VITAMIN and APPENDIX 5: of cartilage. (For cartilages of the knee, see
VITAMINS.) KNEE.)

Carotid Body Caruncle

A small reddish-brown structure measuring 57 Any small fleshy eminence, whether normal or
254 millimetres, situated one on each side abnormal.
of the neck, where the carotid artery divides
into the internal and external carotid arteries. Caseation
Its main function is in controlling breathing so A process which takes place in the tissues in
that an adequate supply of oxygen is main- TUBERCULOSIS and some other chronic dis-
tained to the tissues of the body. Oxygen levels eases. The central part of a diseased area,
are controlled by a reflex operating between the instead of changing into pus and so forming an
carotid body and the respiratory centre in the ABSCESS, changes to a firm cheese-like mass
brain. which may next be absorbed or may be con-
verted into a calcareous deposit and fibrous tis-
Carpal Tunnel Syndrome sue, and so healing results in the formation of a
A condition characterised by attacks of pain scar.
and tingling in the first three or four fingers of
one or both hands. The attacks usually occur at Case-Control Study
night. Carpal tunnel syndrome is caused by Research in which cases that is, persons with
pressure on the median nerve as it passes under a particular condition or receiving a particular
the strong ligament that lies across the front of medication are compared with a group similar
the wrist. The condition may respond to use of in age, sex distribution and social class, etc. who
a night splint on the hand; otherwise a cortico- do not have the condition or who are not
steroid injection under the ligament may help. receiving the drug.
If not, pressure is relieved by surgical division of
the compressing ligament. Casein
That part of milk which forms cheese or curds.
Carpus It is produced by the union of a substance,
The Latin term for the WRIST, composed of caseinogen, dissolved in the milk, with lime
eight small bones firmly joined together with salts also dissolved in the milk the union
ligaments, but capable of a certain amount of being produced by the action of rennin, a fer-
sliding movement over one another. ment from the stomach of the calf. The same
change occurs in the human stomach as the first
Carriers of Disease step in the digestion of milk, and therefore
See INFECTION. when milk is vomited curdled it merely shows
that digestion has begun.
Cartilage
A hard but pliant substance forming parts of Castration
the skeleton for example, the cartilages of the This is literally defined as deprivation of the
ribs, of the larynx and of the ears. Microscopic- power of generation. In practical terms this
ally, cartilage is found to consist of cells involves surgical removal of both OVARIES, or
arranged in twos or in rows, and embedded in a both testicles (see TESTICLE). Such an operation
ground-glass-like material devoid of blood ves- is most commonly associated with the treat-
sels and nerves. The end of every long bone has ment of malignant lesions. In women who have
a smooth layer of hyaline cartilage on it where it reached the menopause, bilateral oophorectomy
 120 Casts

is routinely performed during HYSTERECTOMY, the result of infection or local allergy, catarrh
especially in cases of uterine carcinoma, and is can affect the nose, middle ear and sinuses.
usually performed when removing an ovarian
tumour or malignant cyst. It is essential that the Catatonia
surgeon discusses with a woman before an A condition in which an individual takes up
C operation when it might prove beneficial to odd postures, often accompanied by muteness
remove her ovaries in addition to carrying out or semi-coma. The arms and legs may be
the main procedure. In men, orchidectomy is moved passively by someone else into positions
routine for testicular tumours, and is sometimes that the sufferer then holds for many hours.
carried out when treating prostatic cancer. Catatonia occurs in SCHIZOPHRENIA. It may
also be associated with organic brain disease
Casts such as encephalitis lethargica (see ENCEPHA-
Casts of hollow organs are found in various dis- LITIS), tumours and carbon monoxide
eases. Membraneous casts of the air passages are intoxication.
found in diphtheria and in one form of bron-
chitis, and are sometimes coughed up entire. Catecholamines
Casts of the interior of the bowels are passed in Substances produced in the body from the diet-
cases of mucous colitis associated with constipa- ary AMINO ACIDS, PHENYLALANINE and TYRO-
tion, and casts of the microscopic tubules in the SINE. They include ADRENALINE, NORADREN-
kidneys passed in the urine form one of the ALINE and DOPAMINE which have varying func-
surest signs of glomerulonephritis. (See KIDNEYS, tions, usually as NEUROTRANSMITTERS, in the
DISEASES OF.) sympathetic and central nervous systems (see
under NERVOUS SYSTEM). Their chemical struc-
Catabolism ture is based on a benzene ring with hydroxyl
The breakdown by the body of complex sub- and amine side-chains.
stances to form simpler ones, a process that is
accompanied by the release of energy. Among Catgut
the substances catabolised are nutrients, such as A traditional absorbable SUTURE used in sur-
CARBOHYDRATE and PROTEIN in food, and in
gery for tying cut arteries and stitching wounds.
storage in the body for example, GLYCOGEN. Consisting of twisted COLLAGEN (from sheep
or cattle intestines), catgut is absorbed by
Catalepsy phagocytes (see under PHAGOCYTE) over a vari-
A physical condition in which part or all of the able period. There are two types: plain, and
body becomes rigid. It is characterised by the chromatised or chromic. Synthetic absorbable
adoption of strange often statue-like poses sutures cause less reaction, have a predictable
(CATATONIA), which may pass off within a few absorption period and are more effective.
minutes or may last for several hours (rarely,
days). Typically brought on by a sudden mental
Cathartics
Substances which produce an evacuation of the
trauma, catalepsy may occur with prolonged
bowels (see LAXATIVES). The term cathartic also
depression or some other serious MENTAL
means possessing the power to cleanse.
ILLNESS, and occasionally with EPILEPSY. Suc-
cessful treatment must depend upon due Catherisation
recognition of all precipitating factors and Use of a catheter (see CATHETERS).
circumstances.
Catheters
Cataplexy Hollow tubes, usually made of rubber or plas-
Cataplexy is a condition in which the patient tic, used for passing into various organs of the
has a sudden attack of muscular weakness body, either for investigational purposes or to
affecting the whole body. (See also NARCOLEPSY.) give some form of treatment. They are used
under strict sterile conditions.
Cataract
An opacity of the lens sufficient to cause visual Cardiac catheters are introduced through
impairment (see EYE, DISORDERS OF). a vein in the arm and passed into the heart in
order to diagnose some of the more obscure
Catarrh forms of congenital heart disease, and often as a
Inflammation of the mucous membranes, par- preliminary to operating on the heart.
ticularly those of the air passages, associated
with a copious secretion of mucus. Commonly Endotracheal catheters are used to pass
 CD4/CD8 Count 121

down the TRACHEA into the lungs, usually in coccygeal spinal nerves. The resulting bundle,
the course of administering anaesthetics (see fancifully resembling a horses tail, runs down
under ANAESTHESIA). inside the spinal column until the individual
fibres leave through their respective openings.
Eustachian catheters are small catheters
that are passed along the floor of the nose into Caul C
the Eustachian tube in order to inflate the The piece of AMNION which sometimes covers a
ear. child when he or she is born.

Nasal catheters are tubes passed through Cauliflower Ear

the nose into the stomach to feed a patient who The term applied to the distortion of the
cannot swallow so-called nasal feeding. external ear produced by repeated injury in
sport. Initially it is due to a HAEMATOMA in the
Rectal catheters are passed into the REC- auricle (see EAR). To prevent deformity the
TUM in order to introduce fluid into the rectum. blood should be drawn off from this haem-
atoma as soon as possible, and a firm pressure
Suprapubic catheters are passed into the bandage then applied. Subsequent protection
bladder through an incision in the lower can be given to the ear by covering it with a few
abdominal wall just above the pubis, either to layers of two-way-stretch strapping wound
allow urine to drain away from the bladder, or around the head.
to wash out an infected bladder.
Causalgia
Ureteric catheters are small catheters that A severe burning pain in a limb in which the
are passed up the ureter into the pelvis of the sympathetic and somatic nerves have been
kidney, usually to determine the state of the damaged.
kidney, either by obtaining a sample of urine
direct from the kidney or to inject a radio- Caustics and Cauteries
opaque substance preliminary to X-raying the Caustics and cauteries are used to destroy
kidney. (See PYELOGRAPHY.) tissues the former by chemical action, the
latter by their high temperature. (See
Urethral catheters are catheters that are ELECTROCAUTERY.)
passed along the urethra into the bladder, either
to draw off urine or to wash out the bladder. Cavernous Breathing
A peculiar quality of the respiratory sounds
It is these last three types of catheters that are heard on AUSCULTATION over a cavity in the
most extensively used. lung.

Cat Scanner Cavernous Sinus

See CT SCANNER. A channel for venous blood placed either side of
the sphenoid bone at the base of the SKULL
Cat-Scratch Fever behind the eye sockets. Blood drains into it
An infection in humans caused by a small from the eye, the nose, the brain and part of the
gram-negative BACILLUS (Bartonella henselae). cheek, and leaves via the internal jugular and
The domestic cat is a reservoir for the bacteria, facial veins. Sometimes the sinus becomes
and up to 50 per cent of the cat population may blocked by a blood clot (thrombus), usually a
be affected. The disorder manifests itself as a complication of a nearby bacterial infection. A
skin lesion 310 days after a minor scratch; potentially serious condition, it should be
within two weeks the victims lymph glands treated with thrombolysis and antibiotics.
enlarge and may produce pus. Fever, headache
and malaise occur in some patients. Antibiotics CD4/CD8 Count
do not seem to be effective. The skin lesion An immunological assessment used to monitor
and lymph-gland enlargement subside spon- for signs of organ rejection after transplanta-
taneously within 25 months. tion; it is also used to check the progress of
treatment in patients with HIV (see AIDS/
Cauda HIV). The count measures the ratio of
A tail or a tail-like structure. For example, the helper-induced T-lymphocytes to cytotoxic-
cauda equina (horses tail) is a collection of suppressor lymphocytes. (See LYMPHOCYTE;
nerve roots arising from the lumbar, sacral and IMMUNOLOGY.)
 122 Cefoxitin

Cefoxitin packed together, while many cells, like the

Cefoxitin is a semi-synthetic antibiotic, given white blood corpuscles, retain their primitive
by injection, which is used in the treatment of characters almost entire.
infections due to gram-negative micro- Thus cells are the active agents in forming
organisms such as Proteus which are resistant to the body, and they have a similar function in
C many other antibiotics. repairing its wear and tear. Tumours, and espe-
cially malignant tumours, have a highly cellular
Cell Salvage Transfusion structure, the cells being of an embryonic type,
See TRANSFUSION. or, at best, forming poor imitations of the
tissues in which they grow (see TUMOUR).
Cells
The basic structural unit of body tissues. There Cellulitis
are around 10 billion cells in the human body Inflammation taking place in cellular tissue,
and they are structurally and functionally and usually referring to infection in the sub-
linked to carry out the bodys many complex cutaneous tissue. A related word, cellulite,
activities. which has no medical meaning, is used in the
Every cell consists essentially of a cell-body of slimming business to refer to excess fatty tissue
soft albuminous material called cytoplasm, in in the arms, buttocks and thighs. (See ABSCESS;
which lies a kernel or nucleus which seems to ERYSIPELAS.)
direct all the activities of the cell. Within the
nucleus may be seen a minute body, the nucle- Cellulose
olus; and there may or may not be a cell- A carbohydrate substance forming the skeleton
envelope around all. (See also MITOCHONDRIA.) of most plant structures. It is colourless, trans-
Each cell nucleus carries a set of identical parent, insoluble in water and is practically
CHROMOSOMES, the bodys genetic unaffected by digestion. In vegetable foods it
instructions. therefore adds to the bulk, but it is of no value
Cells vary much in size, ranging in the as a food-stuff. It is found in practically a pure
human body from 00025 mm to about 0025 state in cotton-wool.
mm.
All animals and plants consist at first of a Cement
single cell (the egg-cell, or ovum), which begins See TEETH.
to develop when fertilised by the sperm-cell
derived from the opposite sex. Development Central Nervous System
begins by a division into two new cells, then This comprises the nervous tissue of the brain
into four, and so on till a large mass is formed. and spinal cord, but does not include the cra-
These cells among them stem cells (see STEM nial and spinal nerves and the autonomic ner-
CELL) which have the potential to develop into vous system. This latter group makes up the
a variety of specialised cells then arrange peripheral nervous system. (See BRAIN and
themselves into layers, and form various tubes, SPINAL CORD; NERVOUS SYSTEM.)
rods, and masses which represent in the embryo
the organs of the fully developed animal. (See Central Venous Pressure
FETUS.) The pressure of blood within the right atrium
When the individual organs have been laid of the HEART as measured by a catheter and
down on a scaffolding of cells, these gradually manometer.
change in shape and in chemical composition.
The cells in the nervous system send out long Cephalosporins
processes to form the nerves; those in the These are broad-spectrum antibiotics. Most are
muscles become long and striped in appear- semi-synthetic derivatives of cephalosporin C,
ance; and those which form fat become filled an antibiotic originally derived from a sewage
with fat droplets which distend the cells. Fur- outfall in Sardinia.
ther, they begin to produce, between one First-generation examples still in use include
another, the substances which give the various cephalexin and cefadroxil. They are orally active
tissues their special character. Thus, in the and, along with second-generation cefaclor,
future bones, some cells deposit lime salts and have a similar antimicrobial spectrum. They are
others form cartilage, while in tendons they used for resistant urinary infections and urin-
produce long white fibres of a gelatinous sub- ary infections in pregnancy. Cephalosporins
stance. In some organs the cells change little: have a similar pharmacology to that of penicil-
thus the liver consists of columns of large cells lin, and about 10 per cent of patients allergic to
 Cerebral Palsy 123

penicillin will also be hypersensitive to cepha- in ataxia as can excessive consumption of

losporins. They are effective in treating SEPTI- alcohol, and degeneration of the cerebellum as a
CAEMIA, PNEUMONIA, MENINGITIS, biliary-tract result of an inherited disease. Affected victims
infections and PERITONITIS. may have slurred speech, hand tremors and nys-
Second-generation cefuroxime and cefaman- tagmus (see under EYE, DISORDERS OF).
dole are less vulnerable to penicillinases and are C
useful for treating resistant bacteria and Hae- Cerebellum and Cerebrum
mophilus influenzae and Neisseria gonorrhoea. See BRAIN.
Third-generation cephalosporins include cefo-
taxime, ceftazidime and others; these are more Cerebral Palsy
effective than the second-generation in treating The term used to describe a group of conditions
some gram-negative infections, especially those characterised by varying degrees of paralysis and
causing septicaemia. originating in infancy or early childhood. In
some 80 per cent of cases this takes the form of
Cereal spastic paralysis (muscle stiffness), hence the
Any grass-like plant bearing an edible seed. The now obsolete lay description of sufferers as
important cereals are wheat, oats, barley, maize, spastics. The incidence is believed to be
rice and millet. Along with these are usually around 2 or 25 per 1,000 of the childhood
included tapioca (derived from the cassava community. In the majority of cases the
plant), sago (derived from the pith of the sago abnormality dates from well before birth:
palm) and arrowroot (derived from the root of a among the factors are some genetic malforma-
West Indian plant), all of which consist almost tion of the brain, a congenital defect of the
entirely of starch. Semolina, farola and maca- brain, or some adverse effect on the fetal brain
roni are preparations of wheat. as by infection during pregnancy. Among the
per cent factors during birth that may be responsible is
Water 1012 prolonged lack of oxygen such as can occur dur-
Protein 1012 ing a difficult labour; this may be the cause in
Carbohydrate 6575 up to 15 per cent of cases. In some 1015 per
Fat 058 cent of cases the condition is acquired after
Mineral matter 2 birth, when it may be due to KERNICTERUS,
infection of the brain, cerebral thrombosis or
Composition of cereals embolism, or trauma. Acute illness in infancy,
such as meningitis, may result in cerebral palsy.
Cereals consist predominantly of carbo-
The disease manifests itself in many ways. It
hydrate. They are therefore an excellent source
may not be finally diagnosed and characterised
of energy. On the other hand, their deficiency
until the infant is two years old, but may be
in protein and fat means that to provide a bal-
apparent much earlier even soon after birth.
anced diet, they should be supplemented by
The child may be spastic or flaccid, or the slow,
other foods rich in protein and fat.
writhing involuntary movements known as
per cent athetosis may be the predominant feature.
These involuntary movements often disappear
Carbo- Cellu- during sleep and may be controlled, or even
Water Protein Fat hydrate lose Ash abolished, in some cases by training the child to
Wheat 120 110 17 712 22 19 relax. The paralysis varies tremendously. It may
Oatmeal 72 142 73 659 35 19
involve the limbs on one side of the body
Barley 123 101 19 695 38 24
Rye 110 102 23 723 21 21 (hemiplegia), both lower limbs (paraplegia), or
Maize 125 97 54 689 20 15 all four limbs (DIPLEGIA and QUADRIPLEGIA).
Rice 124 69 04 794 04 05 Learning disability (with an IQ under 70) is
(polished) present in around 75 per cent of all children but
Millet 123 104 39 683 29 22 children with diplegia or athetoid symptoms
Buck wheat 130 102 22 613 111 22 may have normal or even high intelligence.
Composition of certain cereals Associated problems may include hearing or
visual disability, behavioural problems and
Cerebellar Ataxia epilepsy.
Uncoordinated movements, including an The outlook for life is good, only the more
unsteady gait, caused by damage to or disease of severely affected cases dying in infancy.
the cerebellum (see BRAIN). Brain tumours, Although there is no cure, much can be done to
MULTIPLE SCLEROSIS (MS) and stroke can result help these disabled children, particularly if the
 124 Cerebrospinal Fluid

condition is detected at an early stage. Assist- is one of the most common cancers affecting
ance is available from NHS developmental and women throughout the world. In some areas
assessment clinics, supervised by community its incidence is increasing. This cancer has
paediatricians and involving a team approach clearly identifiable precancerous stages with
from experts in education, physiotherapy, abnormal changes occurring in the cells on the
C occupational therapy and speech training. In surface of the cervix: these changes can be
this way many of these handicapped children detected by a CERVICAL SMEAR test. Early can-
reach adulthood able to lead near-normal lives. cer can be cured by diathermy, laser treatment,
Much help in dealing with these children can electrocoagulation or cryosurgery. If the dis-
be obtained from SCOPE (formerly the Spas- ease has spread into the body of the cervix or
tics Society), and Advice Service Capability beyond, more extensive surgery and possibly
Scotland (ASCS). radiotherapy may be needed. The cure rate is
95 per cent if treated in the early stages but
Cerebrospinal Fluid may fall as low as 10 per cent in some severe
The fluid within the ventricles of the brain and cases. Around 3,000 patients are diagnosed as
bathing its surface and that of the spinal cord. having cervical cancer every year in the United
Normally a clear, colourless fluid, its pressure Kingdom, and around 1,500 die from it. Lat-
when an individual is lying on one side is 50 to est figures in England show that the incidence
150 mm water. A LUMBAR PUNCTURE should rates have fallen to under 11 per 100,000
not be done if the intracranial pressure is raised women, while death rates fell by more than
(see HYDROCEPHALUS). 40 per cent during the 1990s. The sexual
The cerebrospinal fluid (CSF) provides use- behaviour of a woman and her male partners
ful information in various conditions and is influences the chances of getting this cancer;
invaluable in the diagnosis of acute and chronic the earlier a woman has sexual intercourse, and
inflammatory diseases of the nervous system. the more partners she has, the greater is the
Bacterial MENINGITIS results in a large increase risk of developing the disease.
in the number of polymorphonuclear LEUCO-
CYTES, while a marked lymphocytosis is seen in Cervical Smear
viral meningitis and ENCEPHALITIS, tuberculous This screening test detects abnormal changes
meningitis and neurosyphilis. The total protein in the cells of the cervix (see CERVIX UTERI),
content is raised in many neurological diseases, enabling an affected woman to have early
being particularly high with neurofibromatosis treatment. The National Health Service has
(see VON RECKLINGHAUSENS DISEASE) and arrangements to check women regularly. A
Guillan-Barr syndrome, while the immuno- womans first test should be within six months
globulin G fraction is raised in MULTIPLE of her first experience of intercourse and
SCLEROSIS (MS), neurosyphilis, and connective- thereafter at three-yearly intervals for the rest
tissue disorders. The glucose content is raised of her life. The test is simple, with some cells
in diabetes (see DIABETES MELLITUS), but may being scraped off the cervix with a spatula and
be very low in bacterial meningitis, when the tissue then being examined
appropriately stained smears or cultures often microscopically.
define the infecting organism. The CSF can
also be used to measure immune proteins pro- Cervical Vertebrae
duced in response to infection, helping diag- The seven bones of the top end of the backbone
nosis in cases where the organism is not grown that form the neck. The first cervical vertebra is
in the laboratory culture. the atlas and this articulates with the base of the
skull. The axis is the second vertebra, which
Cerebrovascular Accident contains a shaft of bone that allows the atlas to
See STROKE.
rotate on it, thus permitting the head to turn.
Cerumen (See SPINAL COLUMN.)
The name for the wax-like secretion found in
the external ear. Cervicitis
Inflammation of the cervix uteri or neck of the
Cervical womb.
Cervical means anything pertaining to the
neck, or to the neck of the womb. Cervix Uteri
The neck of the womb or uterus, placed partly
Cervical Cancer above and partly within the vagina. (See
Cancer of the cervix the neck of the womb UTERUS.)
 Chelating Agents 125

Cetavlon decreased natural protection of the skin. Pro-

See CETRIMIDE. longed immersion in soapy water, followed by
exposure to cold air, results in cracking of the
Cetrimide skin.
Also known as cetavlon, cetrimide is the official Prevention consists of minimising exposure
name for a mixture of alkyl ammonium brom- to detergents and soapy water, and wearing C
ides. It is a potent antiseptic, and as a 1 per cent rubber gloves for all routine household duties.
solution is used for cleaning and disinfecting
wounds, and in the first-aid treatment of burns. Chapped Lips
As it is also a detergent, it is particularly useful See LIPS.
for cleaning the skin, and also for cleansing and
disinfecting greasy and infected bowls and Charcoal
baths. Activated charcoal is a finely powdered material
with a huge surface area (1,000 m2/g) prepared
Chagas Disease from vegetable matter by carbonisation. It is
Chagas disease, or American trypanosomiasis, capable of binding a variety of drugs and chem-
is a disease widespread in Central and South icals and is used in the treatment of poisoning
America, and caused by the Trypanosoma cruzi. as a method of gastric decontamination. It is
The disease is transmitted by the biting bugs, not systemically absorbed. It is also used
Panstrongylus megistus and Triatoma infestans. occasionally for flatulence and as a deodorant
It occurs in an acute and a chronic form. The for skin ulcers.
former, which is most common in children,
practically always affects the heart, and the Charcots Joint
prognosis is poor. The chronic form is com- Named after a 19th-century French physician,
monest in adolescents and young adults and this condition presents as a painless swelling
the outcome depends upon the extent to and disorganisation of the joints resulting from
which the heart is involved. There is no effect- damage to the pain fibres that occurs in dia-
ive drug treatment. (See also SLEEPING betic neuropathy (see DIABETES MELLITUS
SICKNESS.)
Complications), LEPROSY, SYRINGOMYELIA and
syphylitic infection of the spinal cord (see
SYPHILIS).
Chalazion
See EYE, DISORDERS OF.
Cheilosis
Inflammation of the lips. It is common at the
Chalicosis angles of the lips (angular stomatitis), usually as
A disorder of the lungs found among stonecut- a consequence of sagging facial muscles or ill-
ters, and due to the inhalation of fine particles fitting dentures producing folds at the corners
of stone. of the mouth which retain food debris and
allow proliferation of bacteria and candida.
Chalk-Stones Atopic eczema (see SKIN, DISEASES OF) is a
See GOUT. common cause of cheilosis of the whole of the
lips.
Chancre
The primary lesion of SYPHILIS. Cheiropompholyx
Pompholyx is an old name for vesicular eczema
Chancroid (see DERMATITIS) on the palms and fingers
A soft or non-syphilitic venereal sore, caused by (cheiropompholyx) or soles of the feet
a micro-organism known as Haemophilus (podopompholyx).
ducreyi. It is usually acquired by sexual contact,
and responds well to treatment with antibiotics. Chelating Agents
The disease is rare in the UK. Chelating agents are compounds that will ren-
der an ion (usually a metal) biologically inactive
Change of Life by incorporating it into an inner ring structure
See CLIMACTERIC; MENOPAUSE. in the molecule. (Hence the name, from the
Greek chele = claw.) When the complex formed
Chapped Hands in this way is harmless to the body and is
Chapped hands occur in cold weather, when excreted in the urine, such an agent is an effect-
reduced sweat and sebaceous activity leads to ive way of ridding the body of toxic metals such
 126 Chemosis

as mercury. The main chelating agents are Chest

DIMERCAPROL, PENICILLAMINE, desferrioxa- The chest, or THORAX, is the upper part of the
mine and sodium calciumedetate, used for trunk. It is enclosed by the breastbone (ster-
example, in iron poisoning. num) and the 12 ribs which join the sternum
by way of cartilages and are attached to
C Chemosis the spine behind. At the top of the thorax, the
Swelling of the conjunctiva of the EYE, usually opening in between the first ribs admits
caused by inflammation from injury or the windpipe (TRACHEA), the gullet (OESOPH-
infection. AGUS) and the large blood vessels. The bottom
of the thorax is separated from the abdomen
Chemotaxis below by the muscular DIAPHRAGM which is
The ability of certain cells to attract or repel the main muscle of breathing. Other muscles
others. of respiration, the intercostal muscles, lie in
between the ribs. Overlying the ribs are layers
of muscle and soft tissue including the breast
Chemotherapy tissue.
The prevention or treatment of disease by
chemical substances. The term is generally Contents The trachea divides into right
used in two senses: the use of antibacterial and and left main bronchi which go to the two
other drugs to treat infections; and the LUNGS. The left lung is slightly smaller than
administration of ANTIMETABOLITES and other the right. The right has three lobes (upper,
drugs to treat cancer. The discovery by Paul middle and lower) and the left lung has two
Ehrlich in 1910 of the action of Salvarsan in lobes (upper and lower). Each lung is covered
treating syphilis led to the introduction of by two thin membranes lubricated by a thin
sulphonamides in 1935, followed by PENICIL- layer of fluid. These are the pleura; similar
LIN during World War II, which revolution- structures cover the heart (pericardium). The
ised the treatment of common infections. heart lies in the middle, displaced slightly to
Many ANTIBACTERIAL DRUGS have been the left. The oesophagus passes right through
developed since then: these include CEPHA- the chest to enter the stomach just below the
LOSPORINS, cephamycins, TETRACYCLINES, diaphragm. Various nerves, blood vessels and
AMINOGLYCOSIDES, MACROLIDES and CLIN- lymph channels run through the thorax. The
DAMYCIN as well as antituberculous drugs thoracic duct is the main lymphatic drainage
such as STREPTOMYCIN and METRONIDAZOLE. channel emptying into a vein on the left side
Unfortunately, overuse of chemotherapeutic of the root of the neck. (For diseases affecting
drugs in medicine and in animal husbandry the chest and its contents, see HEART, DISEASES
has stimulated widespread resistance among OF; LUNGS, DISEASES OF; CHEST, DEFORMITIES
previously susceptible pathogenic micro- OF.)
organisms. Chemotherapy also plays an
important role in treating tropical diseases, Chest, Deformities of
especially MALARIA, SLEEPING SICKNESS and The healthy chest is gently rounded all over, its
LEPROSY.
contour being more rounded in women by the
Recently chemotherapy has become increas- breast tissue. In cross-section it is oval-shaped
ingly effective in the treatment of cancer. with a longer dimension from side to side than
Numerous drugs, generally CYTOTOXIC, are from back to front.
available; great care is required in their selec-
tion and to minimise side-effects. Certain Barrel chest is found in long-standing
tumours are highly sensitive to chemotherapy ASTHMA or chronic BRONCHITIS and EMPHY-
especially testicular tumours, LEUKAEMIA, SEMA, when the lungs are chronically
LYMPHOMA and various tumours occurring in enlarged. The anterio-posterior dimension of
childhood (e.g. Wilms tumour see NEPHRO- the chest is increased and the ribs are near
BLASTOMA) and may even be cured. horizontal. In this position they can produce
little further expansion of the chest, and
Chenodeoxycholic Acid breathing often relies on accessory muscles in
One of the bile acids (see BILE), used in the the neck lifting up the whole thoracic cage on
treatment of cholesterol gall-stones for patients inspiration.
with mild symptoms when other modern tech-
niques are unsuitable. (See GALL-BLADDER, DIS- Pigeon chest is one in which the cross-
EASES OF.) section of the chest becomes triangular with
 Chilblain 127

the sternum forming a sort of keel in front. It chickenpox, is said to be derived from the
may be related to breathing problems in early resemblance of the eruption to boiled chick-
life. peas.

Rickety chest is uncommon now and is Causes The disease occurs in epidemics
caused by RICKETS in early life. There is a hol- affecting especially children under the age of C
low down each side caused by the pull of ten years. It is due to the varicella zoster virus,
muscles on the softer ribs in childhood. The and the condition is an extremely infectious one
line of knobs produced on each side where from child to child. Although an attack confers
the ribs join their costal cartilages is known as life-long immunity, the virus may lie dormant
the rickety rosary. and manifest itself in adult life as HERPES
ZOSTER or shingles.
Pectus excavatum , or funnel chest, is
quite a common abnormality where the central Symptoms There is an incubation period of
tendon of the diaphragm seems to be too 1421 days after infection, and then the child
short so that the lower part of the sternum is becomes feverish or has a slight shivering, or
displaced inwards and the lower ribs are prom- may feel more severely ill with vomiting and
inent. When severe, it may displace the heart pains in the back and legs. Almost at the same
further to the left side. time, an eruption consisting of red pimples
which quickly change into vesicles filled with
Local abnormalities in the shape of the clear fluid appears on the back and chest, some-
chest occur when there is a deformity in the times about the forehead, and less frequently on
spine such as scoliosis which alters the angles the limbs. These vesicles appear over several
of the ribs. The chest wall may be locally flat- days and during the second day may show a
tened when the underlying lung is reduced in change of their contents to turbid, purulent
size locally over a prolonged period. (See SPINE fluid. Within a day or two they burst, or, at all
AND SPINAL CORD, DISEASES AND INJURIES
events, shrivel up and become covered with
OF.) This may be seen over a scarred area of
brownish crusts. The small crusts have all dried
lung such as that observed in pulmonary up and fallen off in little more than a week and
TUBERCULOSIS.
recovery is almost always complete.

Treatment The fever can be reduced with

Cheyne-Stokes Breathing paracetamol and the itching soothed with
A type of breathing which gets very faint for a CALAMINE lotion. If the child has an immune
short time, then gradually deepens until full disorder, is suffering from a major complication
inspirations are taken for a few seconds, and such as pneumonia, or is very unwell, an anti-
then gradually dies away to another quiet viral drug (aciclovir) can be used. It is likely to
period, again increasing in depth after a few be effective only at an early stage. A vaccine is
seconds and so on in cycles. It is seen in some available in many parts of the world but is not
serious neurological disorders, such as brain used in the UK; the argument against its use is
tumours and stroke, and also in the case of per- that it may delay chickenpox until adult life
sons with advanced disease of the heart or kid- when the disease tends to be much more severe.
neys. When well marked it is a sign that death is
impending, though milder degrees of it do not Chigger
carry such a serious implication in elderly Another name for Trombicula autumnalis,
patients. popularly known as the harvest mite (see BITES
AND STINGS).
Chiasma
This is an X-shaped crossing. The optic chi- Chilblain
asma is where the nerve fibres from the nasal Chilblain, or erythema pernio (see under ERY-
half of each retina cross over the mid line to join THEMA), is an inflamed condition of the hands
the optic tract from the other side. or feet, or occasionally of the ears, and should
not be confused with cracked or CHAPPED
Chickenpox HANDS. Most commonly found in child-
Also known as varicella. An acute, contagious hood and old age, it may be associated with
disease predominantly of children although generally poor health, though there may also be
it may occur at any age characterised by a genetic predisposition. Prevention with good
fever and an eruption on the skin. The name, food, warm clothing, a warm environment, and
 128 Child Abuse

regular exercise to maintain the circulation, is sions exist in the other parts of the United
the best treatment. Kingdom.
When anyone suspects that child abuse is
Child Abuse occurring, contact should be made with the
This traditional term covers the neglect, phys- relevant social-services department or, in Scot-
C ical injury, emotional trauma and sexual abuse land, with the childrens reporter. (See NON-
of a child. Professional staff responsible for the ACCIDENTAL INJURY (NAI); PAEDOPHILIA.)
care and well-being of children now refer to
physical injury as non-accidental injury. Child Child Adoption
abuse may be caused by parents, relatives or Adoption was relatively uncommon until
carers. In England around 35,000 children are World War II, with only 6,000 adoption orders
on local-authority social-service department annually in the UK. This peaked at nearly
child-protection registers that is, are regarded 25,000 in 1968 as adoption became more
as having been abused or at risk of abuse. Phys- socially acceptable and the numbers of babies
ical abuse or non-accidental injury is the most born to lone mothers rose in a climate hostile to
easily recognised form; victims of sexual abuse single parenthood.
may not reveal their experiences until adult- Adoption declined as the availability of
hood, and often not at all. Where child abuse is babies fell with the introduction of the Abor-
suspected, health, social-care and educational tion Act 1968, improving contraceptive services
professionals have a duty to report the case to and increasing acceptability of single
the local authority under the terms of the Chil- parenthood.
dren Act. The authority has a duty to investi- However, with 10 per cent of couples suffer-
gate and this may mean admitting a child to ing infertility, the demand continued, leading
hospital or to local-authority care. Abuse may to the adoption of those previously perceived as
be the result of impulsive action by adults or it difficult to place i.e. physically, intellectually
may be premeditated: for example, the con- and/or emotionally disabled children and ado-
tinued sexual exploitation of a child over sev- lescents, those with terminal illness, and chil-
eral years. Premeditated physical assault is rare dren of ethnic-minority groups.
but is liable to cause serious injury to a child Recent controversies regarding homosexual
and requires urgent action when identified. couples as adoptive parents, adoption of chil-
Adults will go to some lengths to cover up per- dren with or at high risk of HIV/AIDS, tran-
sistent abuse. The childs interests are para- scultural adoption, and the increasing use of
mount but the parents may well be under intercountry adoption to fulfil the needs of
severe stress and also require sympathetic childless couples have provoked urgent con-
handling. sideration of the ethical dilemmas of adoption
In recent years persistent child abuse in some and its consequences for the children, their
childrens homes has come to light, with wide- adoptive and birth families and society
spread publicity following offenders appear- generally.
ances in court. Local communities have also Detailed statistics have been unavailable
protested about convicted paedophiles, released since 1984 but in general there has been a down-
from prison, coming to live in their ward trend with relatively more older children
communities. being placed. Detailed reasons for adoption (i.e.
In England and Wales, local-government interfamily, step-parent, intercountry, etc.) are
social-services departments are central in the not available but approximately one-third are
prevention, investigation and management of adopted from local-authority care.
cases of child abuse. They have four important In the UK all adoptions (including inter-
protection duties laid down in the Children Act family and step-parent adoption) must take
1989. They are charged (1) to prevent children place through a registered adoption agency
from suffering ill treatment and neglect; (2) to which may be local-authority-based or provided
safeguard and promote the welfare of children by a registered voluntary agency. All local
in need; (3) when requested by a court, to authorities must act as agencies, the voluntary
investigate a childs circumstances; (4) to agencies often providing specialist services to
investigate information in concert with the promote and support the adoption of more
NSPCC (National Society for the Prevention of difficult-to-place children. Occasionally an
Cruelty to Children) that a child is suffering adoption allowance will be awarded.
or is likely to suffer significant harm, and to Adoption orders cannot be granted until a
decide whether action is necessary to safeguard child has resided with its proposed adopters for
and promote the childs welfare. Similar provi- 13 weeks. In the case of newborn infants the
 Child Health 129

mother cannot give formal consent to place- while CMOs have mostly been replaced by
ment until the baby is six weeks old, although consultant paediatricians in community child
informal arrangements can be made before this health (CPCCH).
time.
In the UK the concept of responsibility of Screening Screening begins at birth, when
birth parents to their children and their rights every baby is examined for congenital condi- C
to continued involvement after adoption are tions such as dislocated hips, heart malforma-
acknowledged by the Children Act 1989. How- tions, cataract and undescended testicles. Blood
ever, in all discussions the childs interests is taken to find those babies with potentially
remain paramount. The Act also recognises brain-damaging conditions such as HYPO-
adopted childrens need to have information THYROIDISM and PHENYLKETONURIA. Some
regarding their origins. NHS trusts screen for the life-threatening dis-
BAAF British Agencies for Adoption and ease CYSTIC FIBROSIS, although in future it is
Fostering is the national organisation of adop- more likely that finding this disease will be part
tive agencies, both local authority and volun- of prenatal screening, along with DOWNS
tary sector. The organisation promotes and (DOWN) SYNDROME and SPINA BIFIDA. A pro-
provides training service, development and gramme to detect hearing impairment in new-
research; has several specialist professional sub- born babies has been piloted from 2001 in
groups (i.e. medical, legal, etc.); and produces a selected districts to find out whether it would
quarterly journal. be a useful addition to the national screening
Adoption UK is an effective national support programme. Children from ethnic groups at
network of adoptive parents who offer free risk of inherited abnormalities of HAEMO-
information, a listening ear and, to members, GLOBIN (sickle cell disease; thalassaemia see
a quarterly newsletter. under ANAEMIA) have blood tested at some time
National Organisation for Counselling between birth and six months of age.
Adoptees and their Parents (NORCAP) is con-
cerned with adopted children and birth parents Illness prevention At two months, GPs
who wish to make contact. screen babies again for these abnormalities and
The Registrar General operates an Adoption start the process of primary IMMUNISATION.
Contact Register for adopted persons and any- The routine immunisation programme has
one related to that person by blood, half-blood been dramatically successful in preventing ill-
or marriage. Information can be obtained from ness, handicap and deaths: as such it is the cor-
the Office of Population Censuses and Surveys. nerstone of the public health aspect of child
For the addresses of these organisations, see health, with more potential vaccines being
Appendix 2. made available every year. Currently, infants are
immunised against pertussis (see WHOOPING
Childbirth COUGH), DIPHTHERIA, TETANUS, POLIOMYEL-
ITIS, haemophilus (a cause of MENINGITIS,
See PREGNANCY AND LABOUR.
SEPTICAEMIA, ARTHRITIS and epiglottitis) and
meningococcus C (SEPTICAEMIA and menin-
Child Health gitis see NEISSERIACEAE) at two, three and four
Paediatrics is the branch of medicine which months. Selected children from high-risk
deals with diseases of children, but many paedi- groups are offered BCG VACCINE against tuber-
atricians have a wider role, being employed culosis and hepatitis vaccine. At about 13
largely outside acute hospitals and dealing with months all are offered MMR VACCINE (measles,
child health in general. mumps and rubella) and there are pre-school
entry boosters of diphtheria, tetanus, polio,
History Child health services were originally meningococcus C and MMR. Pneumococcal
designed, before the NHS came into being, to vaccine is available for particular cases but is not
find or prevent physical illness by regular yet part of the routine schedule.
inspections. In the UK these were carried out
by clinical medical officers (CMOs) working in Health promotion and educa-
infant welfare clinics (later, child health clinics) tion Throughout the UK, parents are given
set up to fill the gap between general practice their childs personal health record to keep with
and hospital care. The services expanded greatly them. It contains advice on health promotion,
from the mid 1970s; inspections have evolved including immunisation, developmental mile-
into a regular screening and surveillance system stones (when did he or she first smile, sit up,
by general practitioners and health visitors, walk and so on), and graphs called centile
 130 Child Health

charts on which to record height, weight and centres, pre-school teachers or educational
head circumference. There is space for mid- advisers and social workers. Their aims are to
wives, doctors, practice nurses, health visitors diagnose the childs problems, identify his or
and parents to make notes about the child. her therapy needs and make recommendations
Throughout at least the first year of life, both to the local health and educational authorities
C parents and health-care providers set great store on how these should be met. A member of the
by regular weighing, designed to pick up chil- team will usually be appointed as the familys
dren who are failing to thrive. Measuring key worker, who liaises with other members of
length is not quite so easy, but height measure- the team and coordinates the childs manage-
ments are recommended from about two or ment. Regular review meetings are held, gener-
three years of age in order to detect children ally with parents sharing in the decisions made.
with disorders such as growth-hormone Mostly children seen by CDTs are under five
deficiency, malabsorption (e.g. COELIAC DIS- years old, the school health service and edu-
EASE) and psychosocial dwarfism (see below). cational authorities assuming responsibility
All babies have their head circumference thereafter.
measured at birth, and again at the eight-week
check. A too rapidly growing head implies that Special needs The Children Act 1989,
the infant might have HYDROCEPHALUS excess Education Acts 1981, 1986 and 1993, and the
fluid in the hollow spaces within the brain. A Chronically Sick and Disabled Persons Legisla-
too slowly growing head may mean failure tion 1979 impose various statutory duties to
of brain growth, which may go hand in hand identify and provide assistance for children with
with physically or intellectually delayed special needs. They include the chronically ill as
development. well as those with impaired development or dis-
At about eight months, babies receive a sur- abilities such as CEREBRAL PALSY, or hearing,
veillance examination, usually by a health vis- vision or intellectual impairment. Many CDTs
itor. Parents are asked if they have any concerns keep a register of such children so that services
about their childs hearing, vision or physical can be efficiently planned and evaluated. Par-
ability. The examiner conducts a screening test ents of disabled children often feel isolated and
for hearing impairment the so-called distrac- neglected by society in general; they are fre-
tion test; he or she stands behind the infant, quently frustrated by the lack of resources avail-
who is on the mothers lap, and activates a able to help them cope with the sheer hard
standardised sound at a set distance from each work involved. The CDT, through its key
ear, noting whether or not the child turns his or workers, does its best to absorb anger and divert
her head or eyes towards the sound. If the child frustration into constructive actions.
shows no reaction, the test is repeated a few There are other groups of children who come
weeks later; if still negative then referral is made to the attention of child health services. Com-
to an audiologist for more formal testing. munity paediatricians act as advisers to adop-
The doctor or health visitor will also go tion and fostering agencies, vital since many
through the childs developmental progress (see children needing alternative homes have special
above) noting any significant deviation from medical or educational needs or have
normal which merits more detailed examin- behavioural or psychiatric problems. Many see
ation. Doctors are also recommended to exam- a role in acting as advocates, not just for those
ine infants developmentally at some time with impairments but also for socially disadvan-
between 18 and 24 months. At this time they taged children, including those looked after in
will be looking particularly for late walking or childrens homes and those of travellers, asylum
failure to develop appropriate language skills. seekers, refugees and the homeless.

Child development teams (CDTs) Child protection Regrettably, some chil-

Screening and surveillance uncover problems dren come to the attention of child health
which then need careful attention. Most NHS specialists because they have been beaten,
districts have a CDT to carry out this task neglected, emotionally or nutritionally starved
working from child development centres or sexually assaulted by their parents or carers.
usually separate from hospitals. Various therap- Responsibility for the investigation of these
ists, as well as consultant paediatricians in children is that of local-authority social-services
community child health, contribute to the departments. However, child health profes-
work of the team. They include physiotherap- sionals have a vital role in diagnosis, obtaining
ists, occupational therapists, speech therapists, forensic evidence, advising courts, supervising
psychologists, health visitors and, in some the medical aspects of follow-up and teaching
 Children Act 131

doctors, therapists and other professionals in pital clinics with chronic CONSTIPATION; and
training. (See CHILD ABUSE.) little can be done for most viral diseases.
Community child health services can also
School health services Once children boast of successes. The routine immunisation
have reached school age, the emphasis changes. programme has wiped out SMALLPOX, DIPH-
The prime need becomes identifying those with THERIA and POLIOMYELITIS and almost wiped C
problems that may interfere with learning out haemophilus and meningococcal C menin-
including those with special needs as defined gitis, measles and congenital RUBELLA syn-
above, but also those with behavioural prob- drome. WHOOPING COUGH outbreaks continue
lems. Teachers and parents are advised on how but the death and chronic disability rates have
to manage these problems, while health promo- been greatly reduced. Despite these huge health
tion and health education are directed at chil- gains, continuing public scepticism about the
dren. Special problems, especially as children safety of immunisation means that there can be
reach secondary school (aged 1118) include no relaxation in the educational and health-
accidents, substance abuse, psychosexual promotion programme.
adjustment, antisocial behaviour, eating dis- Services for severely and multiply disabled
orders and physical conditions which loom children have improved beyond all recognition
large in the minds of adolescents in particular, with the closure of long-stay institutions, many
such as ACNE, short stature and delayed of which were distinctly child-unfriendly.
puberty. Nonetheless, scarce resources mean that fam-
There is no longer, in the UK, a universal ilies still carry heavy burdens. The incidence of
school health service as many of its functions SUDDEN INFANT DEATH SYNDROME (SIDS) has
have been taken over by general practitioners more than halved as a result of an educational
and hospital and community paediatricians. programme based on firm scientific evidence
However, most areas still have school nurses, that the risk can be reduced by putting babies to
some have school doctors, while others do not sleep on their backs, avoidance of parental
employ specific individuals for these tasks but smoking, not overheating, breast feeding and
share out aspects of the work between GPs, seeking medical attention early for illness.
health visitors, community nurses and consult- Children have fewer accidents and better
ant paediatricians in child health. teeth but new problems have arisen: in the
Complementing their work is the com- 1990s children throughout the developed
munity dental service whose role is to monitor world became fatter. A UK survey in 2004
the whole child populations dental health, pro- found that one in five children are overweight
vide preventive programmes for all, and dental and one in 20 obese. Lack of exercise, the easy
treatment for those who have difficulty using availability of food at all times and in all places,
general dental services for example, children together with the rise of snacking, are likely to
with complex disability. All children in state- provoke significant health problems as these
funded schools are dentally screened at ages five children grow into adult life. Adolescents are at
and 15. greater risk than ever of ill-health through sub-
stance abuse and unplanned pregnancy. Child
Successes and failures Since the incep- health services are facing new challenges in the
tion of the NHS, hospital services for children 21st century.
have had enormous success: neonatal and
infant mortality rates have fallen by two- Children Act
thirds; deaths from PNEUMONIA have fallen The Children Act 1989 (Children Act) intro-
from 600 per million children to a handful; duced major reforms of child-care law. It
and deaths from MENINGITIS have fallen to encourages negotiation and cooperation
one-fifth of the previous level. Much of this between parents, children and professionals to
has been due to the revolution in the man- resolve problems affecting children. The aim is
agement of pregnancy and labour, the inven- to enable children to stay within their own fam-
tion of neonatal resuscitation and neonatal ilies with appropriate back-up from local-
intensive care, and the provision of powerful authority and professional resources. The
antibiotics. emphasis is on empowering families rather than
At the same time, some children acquire HIV paternalistic control. The Act set up a court
infection and AIDS from their affected mothers made up of three tiers the High Court,
(see AIDS/HIV); the prevalence of atopic (see ATOPY) county court and magistrates court each
diseases (ASTHMA, eczema see DERMATITIS, with concurrent jurisdiction. The Act has
HAY FEVER) is rising; more children attend hos- been broadened, clarified and interpreted by
 132 Chills

subsidiary legislation, rules, case law and official and examination in the relevant aspects of anat-
guidance. An equivalent act is in force in omy and physiology, local analgesia, medicine
Scotland. and surgery, as well as in podology and thera-
peutics. The Council holds the register of podi-
Chills atrists. (See APPENDIX 2: ADDRESSES: SOURCES
C See COLD, COMMON. OF INFORMATION, ADVICE, SUPPORT AND SELF-
HELP.)
Chimera
Chimera is an organism, whether plant, animal Chiropractor
or human being, in which there are at least two A person who practises chiropractic mainly a
kinds of tissue differing in their genetic system of physical manipulations of minor dis-
constitution. placements of the spinal column. These minor
displacements (see SUBLUXATION) of the spine
Chinese Avian Influenza are believed to affect the associated or neigh-
A variety of influenza in chickens occurring in bouring nerves and so cause malfunctions of
southern China that in 1997 appeared to jump the muscles throughout the body. By manipu-
the species barrier and infect humans. Some lating the affected part of the spinal column the
cases of the human version of the infection patients complaint, whatever it may be for
occurred in Hong Kong. There were fears of a example, backache is relieved.
serious epidemic which, because of a lack of
natural resistance among humans, might have Chlamydia
led to its worldwide spread. This has not so far A genus of micro-organisms which include
occurred. those responsible for NON-SPECIFIC URETH-
RITIS (NSU), ORNITHOSIS, PSITTACOSIS and
Chiropody TRACHOMA. Chlamydia trachomitis can be
Chiropody (also termed podiatry) is that part of sexually transmitted by both men and women
medical science which is concerned with the and in developed countries is the most signifi-
health of the feet. Its practitioners are specialists cant cause of NSU. Chlamydia and Neisseria
capable of providing a fully comprehensive gonorrhoea (see GONORRHOEA) are the major
foot-health service. This includes the palliation cause of PELVIC INFLAMMATORY DISEASE (PID)
of established deformities and dysfunction, which affects around 100,000 women a year in
both as short-term treatment for immediate the UK, most of whom are under 25 years of
relief of painful symptoms and as long-term age. Chlamydia does not usually cause symp-
management to secure optimum results. This toms unless it spreads to the upper genital tract;
requires the backing of effective appliances and such spread, however, may cause miscarriage
footwear services. It also involves curative foot- (see PREGNANCY AND LABOUR) or ECTOPIC
care, including the use of various therapeutic PREGNANCY. The number of diagnoses of
techniques, including minor surgery and the chlamydia has doubled in the past five years and
prescription and provision of specialised and the incidence of ectopic pregnancies has also
individual appliances. been rising. The infection may well be the main
Among conditions routinely treated are preventable cause of ectopic pregnancy, one
walking disorders in children, injuries to the estimate being that no fewer than half of such
feet of joggers and athletes, corns, bunions and pregnancies are linked to chlamydia infection
hammer toes, ulcers and foot infections. Chir- a figure that is probably much higher in young
opody also has a preventative role which women. A preventive campaign in Sweden
includes inspection of childrens feet and the found that over 15 years, the incidence of
detection of foot conditions requiring treat- ectopic pregnancies fell at the same rate as that
ment and advice and also foot-health educa- of chlamydia diagnoses. Chlamydia infection
tion. The chiropodist is trained to recognise responds well to antibiotic treatment, but edu-
medical conditions which manifest themselves cation of the public about this often silent
in the feet, such as circulatory disorders, DIA- infection, coupled with screening programmes,
BETES MELLITUS and diseases causing would go a long way to reducing the incidence.
ulceration.
The only course of training in the United Chloasma
Kingdom recognised for the purpose of state This is an increase in the melanin pigment of
registration by the Health Professionals Council the skin as a result of hormonal stimulation. It
is the Society of Chiropodists three-year full- is commonly seen in pregnancy and sometimes
time course. The course includes instruction
 Choking 133

in women on the contraceptive pill. It mainly disease in which greenish growths appear under
affects the face. the skin, and in which a change takes place in
the blood resembling that in leukaemia.
Chloral Hydrate
This drug is now rarely used but chloral betaine Chlorophyll
(Welldorm) is occasionally used in the elderly The green colouring matter of plants. Its main C
and in newborns with fits or cerebral irritation use is as a colouring agent, principally for soaps,
after a difficult delivery. oils and fats. It is also being found of value as a
deodorant dressing to remove, or diminish, the
Chlorambucil unpleasant odour of heavily infected sores and
One of several ALKYLATING AGENTS widely used wounds.
in cancer chemotherapy, chlorambucil is an oral
drug commonly used to treat chronic lympho- Chloroquine
cytic LEUKEMIA, non-Hodgkins lymphomas, Chloroquine, which is a 4-aminoquinoline, was
Hodgkins disease (see LYMPHOMA) and ovarian introduced during World War II for the treat-
cancer (see OVARIES, DISEASES OF). Apart from ment of MALARIA. The drug is also used for
suppression of bone-marrow activity, side- PROPHYLAXIS against malaria where the risk of
effects are few. chloroquine-resistant falciparum is still low. It
has also been found of value in the treatment of
Chloramphenicol the skin condition known as chronic discoid
An antibiotic derived from a soil organism, lupus erythematosus, and of rheumatoid
Streptomyces venezuelae. It is also prepared syn- arthritis.
thetically. A potent broad-spectrum antibiotic,
chloramphenicol may, however, cause serious Chlorpromazine
side-effects such as aplastic ANAEMIA, peripheral Chlorpromazine is chemically related to the
NEURITIS, optic neuritis and, in neonates,
antihistamine drug, PROMETHAZINE HYDRO-
abdominal distension and circulatory collapse. CHLORIDE. One of the first antipsychotic
The drug should therefore be reserved for the drugs to be marketed, it is used extensively in
treatment of life-threatening infections such as psychiatry on account of its action in calming
Haemophilus influenzae, SEPTICAEMIA or MEN- psychotic activity without producing undue
INGITIS, typhoid fever (see ENTERIC FEVER) and
general depression or clouding of con-
TYPHUS FEVER, when the causative organism
sciousness. The drug is used particularly in
proves resistant to other drugs. However, SCHIZOPHRENIA and mania. It carries a risk of
because it is inexpensive, it is used widely in contact sensitisation, so should be handled
developing countries. This antibiotic is avail- with care, and the drug has a wide range of
able as drops for use in eye and ear infection, side-effects.
where safety is not a problem.

Chlordane Chlorpropamide
An oral hypoglycaemic agent, chlorpropamide
An insecticide which has been used sucessfully
was for many years used to treat diabetes (see
against flies and mosquitoes resistant to DDT
DIABETES MELLITUS). It has been largely super-
(see DICHLORODIPHENYL TRICHLOROETHANE),
seded by more effective oral agents with fewer
and for the control of ticks and mites. It
side-effects, such as gliclazide.
requires special handling as it is toxic to humans
when applied to the skin.
Chlortetracycline
See TETRACYCLINES.
Chlordiazepoxide
A widely used anti-anxiety drug. (See TRAN-
QUILLISERS; BENZODIAZEPINES.)
Choking
Choking is the process which results from an
Chlorhexidine obstruction to breathing situated in the larynx
An antiseptic which has a bacteriostatic action (see AIR PASSAGES). It may occur as the result of
against many bacteria. disease causing swelling round the glottis (the
entrance to the larynx), or of some nervous dis-
Chlorine orders that interfere with the regulation of the
See SODIUM HYPOCHLORITE. muscles which open and shut the larynx. Gen-
erally, however, it is due to the irritation of a
Chloroma piece of food or other substance introduced by
Chloroma, or green cancer, is the name of a the mouth, which provokes coughing but only
 134 Cholagogues

partly interferes with breathing. As the mucous Cholecystectomy

membrane lining the upper part of the latter is Removal of the gall-bladder (see LIVER) by
especially sensitive, coughing results in order to operation.
expel the cause of irritation. At the same time, if
the foreign body is of any size, lividity of the Cholecystitis
C face appears, due to partial suffocation (see Inflammation of the gall-bladder (see GALL-
ASPHYXIA). BLADDER, DISEASES OF).

Treatment The choking person should take Cholecystography

slow, deep inspirations, which do not force the The process whereby the gall-bladder (see LIVER)
particle further in (as sudden catchings of the is rendered radio-opaque and therefore visisble
breath between the coughs do), and which pro- on an X-ray film.
duce more powerful coughs. If the coughing is
weak, one or two strong blows with the palm of Cholecystokinin
the hand over either shoulder blade, timed to The hormone (see HORMONES) released from the
coincide with coughs, aid the effect of the lining membrane of the DUODENUM when food
coughing. If this is ineffective, the Heimlich is taken, and which initiates emptying of the
manoeuvre may be used. This involves hug- gall-bladder (see LIVER).
ging the person from behind with ones hands
just under the diaphragm. A sudden upward Cholelithiasis
compressive movement is made which serves The presence of gall-stones in the bile ducts
to dislodge any foreign body. In the case of a and/or in the gall-bladder. (See GALL-BLADDER,
baby, sit down with left forearm resting on DISEASES OF.)
thigh. Place the baby chest-down along the
forearm, holding its head and jaw with the Cholelithotomy
fingers and thumb. The infants head should The removal of gall-stones from the gall-
be lower than its trunk. Gently deliver three or bladder or bile ducts (see GALL-BLADDER, DIS-
four blows between the shoulder blades with EASES OF), when CHOLECYSTECTOMY or
the free hand. The resuscitator should not LITHOTRIPSY are inappropriate or not possible.
attempt blind finger-sweeps at the back of the It involves a cholecystomy, an operation to
mouth; these can impact a foreign body in the open the gall-bladder.
larynx.
If normal breathing (in adult or child) can- Cholera
not be quickly restored, seek urgent medical Bacterial infection caused by Vibrio cholerae.
help. Sometimes an emergency TRACHE- The patient suffers profuse watery DIARRHOEA,
OSTOMY is necessary to restore the air supply and resultant dehydration and electrolyte
to the lungs. (See APPENDIX 1: BASIC FIRST imbalance. Formerly known as the Asiatic chol-
AID.) era, the disease has occurred in epidemics and
pandemics for many centuries. When it entered
Cholagogues Europe in 1853, Dr John Snow, a London
Substances which increase the flow of BILE by anaesthetist, carried out seminal epidemi-
stimulating evacuation of the gall-bladder (see ological work in Soho, London, which estab-
LIVER). The great majority of these act only by lished that the source of infection was con-
increasing the activity of the digestive organs, taminated drinking water derived from the
and so producing a flow of bile already stored Broad Street pump. Several smaller epidemics
up in the gall-bladder. Substances which stimu- involved Europe in the latter years of the 19th
late the liver to secrete more bile are known as century, but none has arisen in Britain or the
CHOLERETIC. United States for many years. In 1971, the El
Tor biotype of V. cholerae emerged, replacing
Cholangiography much of the classical infection in Asia and, to a
The process whereby the bile ducts (see BILE much lesser extent, Europe; parts of Africa were
DUCT) and the gall-bladder (see LIVER) are ren- seriously affected. Recently a non-01 strain has
dered radio-opaque and therefore visible on an arisen and is causing much disease in Asia.
X-ray film. Cholera remains a major health problem (this is
technically the seventh pandemic) in many
Cholangitis countries of Asia, Africa and South America. It
Inflammation of the bile ducts (see BILE DUCT; is one of three quarantinable infections.
GALL-BLADDER, DISEASES OF). Incubation period varies from a few hours to
 Cholesterol 135

five days. Watery diarrhoea may be torrential body cells and so widely distributed throughout
and the resultant dehydration and electrolyte the body. It is especially abundant in the brain,
imbalance, complicated by cardiac failure, nervous tissue, adrenal glands and skin. It is also
commonly causes death. The victims skin elas- found in egg yolk and gall-stones (see GALL-
ticity is lost, the eyes are sunken, and the radial BLADDER, DISEASES OF). Cholesterol plays an
pulse may be barely perceptible. Urine produc- important role in the body, being essential for C
tion may be completely suppressed. Diagnosis the production of the sex hormones as well as
is by detection of V. cholerae in a faecal sample. for the repair of membranes. It is also the source
Treatment consists of rapid rehydration. from which BILE acids are manufactured. The
Whereas the intravenous route may be required total amount in the body of a man weighing 70
in a severe case, in the vast majority of patients kilograms (10 stones) is around 140 grams, and
oral rehydration (using an appropriate solution the amount present in the blood is 3678
containing sodium chloride, glucose, sodium mmol per litre or 150250 milligrams per 100
bicarbonate, and potassium) gives satisfactory millilitres.
results. Proprietary rehydration fluids do not A high blood-cholesterol level that is, one
always contain adequate sodium for rehydra- over 6 mmol per litre or 238 mg per 100 ml
tion in a severe case. ANTIBIOTICS, for example, is undesirable as there appears to be a correl-
tetracycline and doxycycline, reduce the period ation between a high blood cholesterol and
during which V. cholerae is excreted (in children ATHEROMA, the form of arterial degenerative
and pregnant women, furazolidone is safer); in disease associated with coronary thrombosis
an epidemic, rapid resistance to these, and other and high blood pressure. This is well exempli-
antibiotics, has been clearly demonstrated. Pre- fied in DIABETES MELLITUS and HYPOTHYROID-
vention consists of improving public health ISM, two diseases in which there is a high blood
infrastructure in particular, the quality of cholesterol, sometimes going as high as 20
drinking water. When supplies of the latter are mmol per litre; patients with these diseases are
satisfactory, the infection fails to thrive. known to be particularly prone to arterial dis-
Though there have recently been large epidem- ease. There is also a familial disease known as
ics of cholera in much of South America and hypercholesterolaemia, in which members of
parts of central Africa and the Indian sub- affected families have a blood cholesterol of
continent, the risk of tourists and travellers con- around 18 mmol per litre or more, and are
tracting the disease is low if they take simple particularly liable to premature degenerative
precautions. These include eating safe food disease of the arteries. Many experts believe that
(avoid raw or undercooked seafood, and wash there is no safe level and that everybody
vegetables in clean water) and drinking clean should attempt to keep their cholesterol level as
water. There is no cholera vaccine at present low as possible.
available in the UK as it provides little protec- Cholesterol exists in three forms in the
tion and cannot control spread of the disease. blood: high-density lipoproteins (HDLs) which
Those travelling to countries where it exists are believed to protect against arterial disease,
should pay scrupulous attention to food and and a low-density version (LDLs) and very low-
water cleanliness and to personal hygiene. density type (VLDLs), these latter two being
risk factors.
Choleretic The rising incidence of arterial disease in
The term applied to a drug that stimulates the western countries in recent years has drawn
flow of BILE. attention to this relationship between high
levels of cholesterol in the blood and arterial
Cholestasis disease. The available evidence indicates that
A reduction or stoppage in the flow of BILE into there is a relationship between blood-
the intestine caused either by a blockage such as cholesterol levels and the amount of fat con-
a stone in the BILE DUCT or by liver disease sumed; however, the blood-cholesterol level
disturbing the production of bile. The first type bears little relationship to the amount of choles-
is called extrahepatic biliary obstruction and the terol consumed, most of the cholesterol in the
second, intrahepatic cholestasis. The patient body being produced by the body itself.
develops jaundice and itching and passes dark On the other hand, diets high in saturated
urine and pale faeces. Cholestasis may fatty acids chiefly animal fats such as red
occasionally occur during pregnancy. meat, butter and dripping tend to raise the
blood-cholesterol level; while foods high in
Cholesterol unsaturated fatty acids chiefly vegetable
A LIPID that is an important constituent of products such as olive and sunflower oils, and
 136 Choline

oily fish such as mackerel and herring tend to the symptoms, as can the drugs used to treat
lower it. There is a tendency in western society PARKINSONISM. Types of chorea include HUNT-
to eat too much animal fat, and current health INGTONS CHOREA, an inherited disease, and
recommendations are for everyone to decrease SYDENHAMS CHOREA, which is autoimmune.
saturated-fat intake, increase unsaturated-fat There is also a degenerative form senile
C intake, increase daily exercise, and avoid obes- chorea.
ity. This advice is particulary important for
people with high blood-cholesterol levels, with Choriocarcinoma
diabetes mellitus, or with a history of coronary A form of cancer affecting the CHORION, in the
thrombosis (see HEART, DISEASES OF). As well as treatment of which particularly impressive
a low-cholesterol diet, people with high choles- results are being obtained from the use of
terol values or arterial disease may be given methotrexate.
cholesterol-reducing drugs such as STATINS, but
this treatment requires full clinical assessment Chorion
and ongoing medical monitoring. Recent This is the more external of the two fetal
research involving the worlds largest trial into membranes. (See PLACENTA.)
the effects of treatment to lower concentrations
of cholesterol in the blood showed that routine Chorionic Gonadotrophic
use of drugs such as statins reduced the inci-
dence of heart attacks and strokes by one-third, Hormone
even in people with normal levels of cholesterol. A hormone produced by the PLACENTA during
The research also showed that statins benefited pregnancy. It is similar to the pituitary GON-
women and the over-70s. ADOTROPHINS, which are blocked during preg-
nancy. Large amounts appear in a womans
Choline urine when she is pregnant and are used as the
One of the many constituents of the vitamin B basis for pregnancy tests. Human gonado-
complex. Lack of it in the experimental animal trophins are used to treat delayed puberty and
produces a fatty liver. It is found in egg-yolk, premenstrual tension.
liver, and meat. The probable daily human
requirement is 500 mg, an amount amply Choroid
covered by the ordinary diet. Choline can be See EYE.
synthesised by the body (see APPENDIX 5:
VITAMINS). Choroiditis
See UVEITIS.
Cholinergic
A description of nerve fibres that release Choroid Plexus
ACETYLCHOLINE as a NEUROTRANSMITTER. An extensive web of blood vessels occurring in
the ventricles of the BRAIN and producing the
Cholinesterase CEREBROSPINAL FLUID.
An ENZYME that helps to break down the
neurotransmitter compound ACETYLCHOLINE. Christmas Disease
A hereditary disorder of blood coagulation
Chondroma which can only be distinguished from HAEMO-
A TUMOUR composed in part of cartilage. PHILIA by laboratory tests. It is so-called after
the surname of the first case reported in this
Chorda country. About one in every ten patients clinic-
A nerve-fibre, tendon or cord. ally diagnosed as haemophiliac has in fact
Christmas disease. It is due to lack in the blood
Chorea of Factor IX (see COAGULATION).
Chorea, or St Vituss dance, is the occurrence of
short, purposeless involuntary movements of Chromaffin
the face, head, hands and feet. Movements are A term applied to certain cells and organs in the
sudden, but the affected person may hold the body, such as part of the adrenal glands, which
new posture for several seconds. Chorea is often have a peculiar affinity for chrome salts. These
accompanied by ATHETOSIS, when it is termed cells and tissues generally are supposed to
choreoathetosis. Choreic symptoms are often secrete substances which have an important
due to disease of the basal ganglion in the brain. action in maintaining the tone and elasticity of
The withdrawal of phenothiazines may cause the blood vessels and muscles.
 Chronic Obstructive Pulmonary Disease (COPD) 137

Chromatin define CFS/ME). Despite the stereotype of

The genetic material found in the nucleus of a yuppie flu, epidemiological research has
cell. It consists of PROTEIN and deoxyribo- shown that the condition occurs in all socio-
nucleic acid (DNA). During mitotic division of economic and ethnic groups. It is commoner in
the cell, chromatin condenses into women and can also occur in children.
CHROMOSOMES. In the 19th century CFS was called neur- C
asthenia. In the UK, myalgic encephalomyelitis
Chromic Acid (ME) is often used, a term originally introduced
Chromic acid is used in several industries, par- to describe a specific outbreak such as the one at
ticularly in chromium plating. Unless precau- the Royal Free Hospital, London in 1955. The
tions are taken it may lead to dermatitis of the term is inaccurate as there is no evidence of
hands, arms, chest and face. It may also cause inflammation of the brain and spinal cord (the
deep ulcers, especially of the nasal septum and meaning of encephalomyelitis). Doctors prefer
knuckles. the term CFS, but many patients see this as
derogatory, perceiving it to imply that they are
Chromosomes merely tired all the time rather than having a
The rod-shaped bodies to be found in the disabling illness.
nucleus of every cell in the body. They contain The cause (or causes) are unknown, so the
the GENES, or hereditary elements, which estab- condition is classified alongside other medic-
lish the characteristics of an individual. Com- ally unexplained syndromes such as IRRITABLE
posed of a long double-coiled filament of DNA, BOWEL SYNDROME (IBS) and multiple chemical
they occur in pairs one from the maternal, the sensitivity all of which overlap with CFS. In
other from the paternal and human beings many patients the illness seems to start
possess 46, made up of 23 pairs. The number of immediately after a documented infection, such
chromosomes is specific for each species of as that caused by EPSTEIN BARR VIRUS, or after
animal. Each chromosone can duplicate an viral MENINGITIS, Q FEVER and TOXO-
exact copy of itself between each cell division. PLASMOSIS. These infections seem to be a trig-
(See GENETIC CODE; GENETICS; HEREDITY; ger rather than a cause: mild immune activation
MEIOSIS; SEX CHROMOSOMES.) is found in patients, but it is not known if this is
cause or effect. The bodys endocrine system is
Chronic Disorder disturbed, particularly the hypothalamo-
A persistent or recurring condition or group of pituitary-adrenal axis, and levels of cortisol are
symptoms. Chronic disorders are customarily often a little lower than normal the opposite
contrasted with acute diseases which start sud- of what is found in severe depression. Psychi-
denly and last a short time. The symptoms of atric disorder, usually depression and/or anx-
acute disease often include breathlessness, iety, is associated with CFS, with rates too high
fever, severe pain and malaise, with the to be explained solely as a reaction to the dis-
patients condition changing from day to day ability experienced.
or even hour to hour. Those suffering from Because we do not know the cause, the
chronic conditions for example, severe arth- underlying problem cannot be dealt with effect-
ritis, protracted lung disease, ASTHMA or SILI- ively and treatments are directed at the factors
COSIS should be distinguished from those leading to symptoms persisting. For example, a
with a static disability following a stroke or slow increase in physical activity can help many,
injury. Chronic disorders steadily deteriorate, as can COGNITIVE BEHAVIOUR THERAPY. Too
often despite treatment and the patient is much rest can be harmful, as muscles are rap-
increasingly unable to carry out his or her daily idly weakened, but aggressive attempts at
activities. coercing patients into exercising can be
counter-productive as their symptoms may
Chronic Fatigue Syndrome (CFS) worsen. Outcome is influenced by the presence
See also MYALGIC ENCEPHALOMYELITIS (ME). A of any pre-existing psychiatric disorder and the
condition characterised by severe, disabling sufferers beliefs about its causes and treatment.
mental and physical fatigue brought on by Research continues.
mental or physical activity and associated with a
range of symptoms including muscle pain, Chronic Obstructive Pulmonary
headaches, poor sleep, disturbed moods and Disease (COPD)
impaired concentration. The prevalence of the This is a term encompassing chronic BRON-
condition is between 0.2 and 2.6 per cent of the CHITIS, EMPHYSEMA, and chronic ASTHMA
population (depending on how investigators where the airflow into the lungs is obstructed.
 138 Chronic Obstructive Pulmonary Disease (COPD)

Chronic bronchitis is typified by chronic tum. Small airways become obstructed and the
productive cough for at least three months in alveoli lose their elasticity. COPD usually starts
two successive years (provided other causes such with repeated attacks of productive cough,
as TUBERCULOSIS, lung cancer and chronic commonly following winter colds; these
heart failure have been excluded). The charac- attacks progressively worsen and eventually the
C teristics of emphysema are abnormal and per- patient develops a permanent cough. Recurrent
manent enlargement of the airspaces (alveoli) at respiratory infections, breathlessness on exer-
the furthermost parts of the lung tissue. Rup- tion, wheezing and tightness of the chest fol-
ture of alveoli occurs, resulting in the creation low. Bloodstained and/or infected sputum are
of air spaces with a gradual breakdown in the also indicative of established disease. Among
lungs ability to oxygenate the blood and the symptoms and signs of patients with
remove carbon dioxide from it (see LUNGS). advanced obstruction of airflow in the lungs
Asthma results in inflammation of the airways are:
with the lining of the BRONCHIOLES becoming
hypersensitive, causing them to constrict. The
RHONCHI (abnormal musical sounds heard
through a STETHOSCOPE when the patient
obstruction may spontaneously improve or do breathes out).
so in response to bronchodilator drugs. If an marked indrawing of the muscles between
asthmatic patients airway-obstruction is char- the ribs and development of a barrel-shaped
acterised by incomplete reversibility, he or she is chest.
deemed to have a form of COPD called asth- loss of weight.
matic bronchitis; sufferers from this disorder CYANOSIS in which the skin develops a blue
cannot always be readily distinguished from tinge because of reduced oxygenation of
those people who have chronic bronchitis and/ blood in the blood vessels in the skin.
or emphysema. Symptoms and signs of emphy- bounding pulse with changes in heart
sema, chronic bronchitis and asthmatic bron- rhythm.
chitis overlap, making it difficult sometimes to OEDEMA of the legs and arms.
make a precise diagnosis. Patients with com-
pletely reversible airflow obstruction without
decreasing mobility.
Some patients with COPD have increased
the features of chronic bronchitis or emphy- ventilation of the alveoli in their lungs, but the
sema, however, are considered to be suffering levels of oxygen and carbon dioxide are normal
from asthma but not from COPD. so their skin colour is normal. They are, how-
The incidence of COPD has been increasing, ever, breathless so are dubbed pink puffers.
as has the death rate. In the UK around 30,000 Other patients have reduced alveolar ventila-
people with COPD die annually and the dis- tion which lowers their oxygen levels causing
order makes up 10 per cent of all admissions to cyanosis; they also develop COR PULMONALE, a
hospital medical wards, making it a serious form of heart failure, and become oedematous,
cause of illness and disability. The prevalence, so are called blue bloaters.
incidence and mortality rates increase with age,
and more men than women have the disorder, Investigations include various tests of lung
which is also more common in those who are function, including the patients response to
socially disadvantaged. bronchodilator drugs. Exercise tests may help,
but radiological assessment is not usually of
Causes The most important cause of COPD great diagnostic value in the early stages of the
is cigarette smoking, though only 15 per cent of disorder.
smokers are likely to develop clinically signifi-
cant symptoms of the disorder. Smoking is Treatment depends on how far COPD has
believed to cause persistent airway inflamma- progressed. Smoking must be stopped also an
tion and upset the normal metabolic activity in essential preventive step in healthy individuals.
the lung. Exposure to chemical impurities Early stages are treated with bronchodilator
and dust in the atmosphere may also cause drugs to relieve breathing symptoms. The next
COPD. stage is to introduce steroids (given by inhal-
ation). If symptoms worsen, physiotherapy
Signs and symptoms Most patients develop breathing exercises and postural drainage is
inflammation of the airways, excessive growth valuable and annual vaccination against INFLU-
of mucus-secreting glands in the airways, and ENZA is strongly advised. If the patient develops
changes to other cells in the airways. The result breathlessness on mild exertion, has cyanosis,
is that mucus is transported less effectively wheezing and permanent cough and tends to
along the airways to eventual evacuation as spu- HYPERVENTILATION, then oxygen therapy
 Cimex Lectularius 139

should be considered. Antibiotic treatment is Chyme

necessary if overt infection of the lungs Partly digested food as it issues from the stom-
develops. ach into the intestine. It is very acid and grey in
colour, containing salts and sugars in solution,
Complications Sometimes rupture of the and the animal food softened into a semi-liquid
pulmonary bullae (thin-walled airspaces pro- mass. It is next converted into CHYLE. C
duced by the breakdown of the walls of the
alveoli) may cause PNEUMOTHORAX and also Chymopapain
exert pressure on functioning lung tissue. An ENZYME obtained from the paw-paw, which
Respiratory failure and failure of the right side is being used in the treatment of prolapsed
of the heart (which controls blood supply to the INTERVERTEBRAL DISC. When injected into the
lungs), known as cor pulmonale, are late com- disc it dissolves the cartilage tissue.
plications in patients whose primary problem is
emphysema. Chymotrypsin
An ENZYME produced by the PANCREAS which
Prognosis This is related to age and to the digests protein. It is used as an aid in operations
extent of the patients response to broncho- for removal of a cataract (see ZONULOLYSIS), and
dilator drugs. Patients with COPD who also by inhalation to loosen and liquefy
develop raised pressure in the heart/lung secretions in the windpipe and bronchi.
circulation and subsequent heart failure (cor
pulmonale) have a bad prognosis. Cicatrix
Another word for scar.
Chronic Sick and Disabled Act
1970 Ciclosporin A
UK legislation that provides for the identifica- A drug used to prevent the rejection of trans-
tion and care of individuals who have an incur- planted organs such as the heart and kidneys.
able chronic or degenerative disorder. The (See TRANSPLANTATION.)
patients are usually distinguished from elderly
people with chronic disorders. Local authorities Cilia
identify relevant individuals and arrange for A term applied to minute, lash-like processes
appropriate services. The legislation does not, which are seen with the aid of the microscope
however, compel doctors and nurses in the upon the cells covering certain mucous
community to inform local authorities of membranes for example, the TRACHEA (or
potential beneficiaries. This may be because the windpipe) and nose and which maintain
individuals concerned dislike being on a register movement in the fluid passing over these mem-
of disabled, or because questions of con- branes. They are also found on certain bacteria
fidentiality prevent health staff from reporting which have the power of rapid movement.
the persons condition.
Ciliary Body
Chyle That part of the EYE that connects the iris and
The milky fluid which is absorbed by the the choroid. The ciliary ring is next to the
lymphatic vessels of the intestine. The absorbed choroid; the ciliary processes comprise many
portion consists of fats in very fine emulsion, ridges behind the iris, to which the lenss sus-
like milk, so that these vessels receive the name pensory ligament is attached; and the ciliary
of lacteals (L. lac, milk). This absorbed chyle muscle contracts to change the curvature of the
mixes with the lymph and is discharged into the lens and so adjust the accommodation of the
thoracic duct, a vessel, which passes up through eye.
the chest to open into the jugular vein on the
left side of the neck, where the chyle mixes with Cimetidine
the blood. Cimetidine is a drug (known as an H2 receptor
antagonist) that is widely used in the treatment
Chyluria of PEPTIC ULCER. It acts by reducing the
The passage of CHYLE in the urine. This results hyperacidity of the gastric juice by antagonising
in the passing of a milky-looking urine. It is one histamine receptors in the stomach.
of the manifestations of FILARIASIS, where it is
due to obstruction of the LYMPHATICS by the Cimex Lectularius
causative parasite. See BED BUG.
 140 Cinchona

Cinchona The circle is maintained always in one direc-

The general name for several trees in the bark of tion by four valves, situated one at the outlet
which QUININE is found. This bark is also from each cavity of the heart.
known as Jesuits bark, having been first The blood in the arteries going to the body
brought to notice by Spanish priests in South generally is bright red, that in the veins dull red
C America, and first brought to Europe by the in colour, owing to the former being charged
Countess of Cinchon, wife of the Viceroy of with oxygen and the latter with carbon dioxide
Peru, in 1640. The red cinchona bark contains (see RESPIRATION). For the same reason the
the most quinine; quinine is usually prepared blood in the pulmonary artery is dark, that in
from this. Various extracts and tinctures are the pulmonary veins is bright. There is no direct
made direct from cinchona bark, and used in communication between the right and left sides
place of quinine. of the heart, the blood passing from the right
ventricle to the left atrium through the lungs.
Ciprofloxacin In the embryo, before birth, the course of
A quinolone antibiotic (see QUINOLONES) used circulation is somewhat different, owing to the
to treat typhoid and paratyphoid infections (see fact that no nourishment comes from the
ENTERIC FEVER). bowels nor air into the lungs. Accordingly, two
large arteries pass out of the navel, and convey
Circle of Willis blood to be changed by contact with maternal
A circle of arteries at the base of the brain, blood (see PLACENTA), while a large vein brings
formed by the junction of the basilar, posterior this blood back again. There are also communi-
cerebral, internal carotid and anterior cerebral cations between the right and left atria, and
arteries. Congenital defects may occur in these between pulmonary artery and aorta. The latter
arteries and lead to the formation of aneurysm is known as the ductus arteriosus. At birth all
(see ANEURYSM). these extra vessels and connections close and
rapidly shrivel up.
Circulatory System of the Blood
The course of the circulation is as follows: the Circumcision
veins pour their blood, coming from the head, A surgical procedure to remove the prepuce of
trunk, limbs and abdominal organs, into the the PENIS in males and a part or all of the
right atrium of the HEART. This contracts and external genitalia in females (see below). Circum-
drives the blood into the right ventricle, which cision is mainly done for religious or ethnic
then forces the blood into the LUNGS by way of reasons; there is virtually no medical or surgical
the pulmonary artery. Here it is contained in reason for the procedure. (The PREPUCE is not
thin-walled capillaries, over which the air plays normally retractable in infancy, so this is not an
freely, and through which gases pass readily out indication for the operation by the age of four
and in. The blood gives off carbon dioxide the prepuce is retractable in most boys.) Ameri-
(CO2) and takes up oxygen (see RESPIRATION), cans are more enthusiastic about circumcision,
and passes on by the pulmonary veins to the left and the reason offered is that cancer of the penis
atrium of the heart. The left atrium expels it occurs only when a foreskin is present. This is
into the left ventricle, which forces it on into however a rare disease. In the uncircumcised
the aorta, by which it is distributed all over the adult there is an increased transmission of her-
body. Passing through capillaries in the various pes and cytomegaloviruses during the repro-
tissues, it enters venules, then veins, which ductive years, but this can be reduced by
ultimately unite into two great veins, the adequate cleansing. PHIMOSIS (restricted open-
superior and the inferior vena cava, these ing of the foreskin) is sometimes an indication
emptying into the right atrium. This complete for circumcision but can also be dealt with by
circle is accomplished by any particular drop of division of adhesions between the foreskin and
blood in about half a minute. glans under local anesthetic. Haemorrhage,
In one part of the body there is a further infection and meatal stenosis are rare complica-
complication. The veins coming from the tions of circumcision.
bowels, charged with food material and other Circumcision in women is a damaging pro-
products, split up, and their blood undergoes a cedure, involving the removal of all or parts of
second capillary circulation through the liver. the CLITORIS, LABIA majora and labia minora,
Here it is relieved of some food material and sometimes combined with narowing of the
purified, and then passes into the inferior vena entrance to the VAGINA. Total removal of the
cava, and so to the right atrium. This is known external female genitalia, including the clitoris,
as the portal circulation. is called INFIBULATION. The result may be psy-
 Cleft Foot 141

chological and sexual problems and complica- Claustrophobia

tions in childbirth, with no known benefit to Morbid fear of being in a confined space, or
the womans health, though cultural pressures the fear experienced while in it. Claustro-
have resulted in its continuation in some Mus- phobia may develop because of a previous
lim and African countries, despite widespread unpleasant experience in a confined space.
condemnation of the practice and campaigns to COGNITIVE BEHAVIOUR THERAPY may help C
stop it. It has been estimated that more than 80 patients whose daily lives are seriously affected
million women in 30 countries have been by this disorder.
circumcised.
Clavicle
Cirrhosis The bone which runs from the upper end of the
Cirrhosis, or FIBROSIS, is a diseased condition, breastbone towards the tip of the shoulder
in which the proper tissue is replaced by fibrous across the root of the neck. It supports the
tissue similar to scar tissue. The name cirrhosis upper limb, keeps it out from the side, and gives
was originally given by Laennec to the disease as breadth to the shoulders. The bone is shaped
occurring in the liver, because of its yellow col- like an f with two curves, which give it
our. (See LIVER, DISEASES OF.) increased strength. It is, however, liable to be
broken by falls on the hand or on the shoulder,
Cirsoid Aneurysm and is the most frequently fractured bone in the
The condition in which a group of arteries body. (See BONE, DISORDERS OF.)
become abnormally dilated and tortuous.
Claw-Foot
Cisplatin Claw-foot, or PES CAVUS, is a familial deformity
A toxic drug with an alkylating action that gives of the foot characterised by an abnormally high
it useful anti-tumour properties, especially arch of the foot accompanied by shortening of
against solid tumours such as ovarian and tes- the foot, clawing of the toes, and inversion, or
ticular cancers (see CYTOTOXIC). turning inwards, of the foot and heel. Its main
effect is to impair the resilience of the foot
Citric Acid resulting in a stiff gait and aching pain. Milder
This is responsible for the sharp taste associated cases are treated with special shoes fitted with a
with citrus fruits, such as lemons and limes, sponge rubber insole. More severe cases may
and other fruits such as currants and rasp- require surgical treatment.
berries. Although chemically different from, it
is similar in action and appearance to tartaric Claw-Hand
acid, obtained from grapes and other fruits, A (contraction) deformity of the hand and fin-
and similar to malic acid, found in apples and gers, especially of the ring and little fingers.
pears. The condition is generally due to paralysis of
the ULNAR NERVE. A somewhat similar condi-
CJD tion is produced by contraction of the fibrous
See CREUTZFELDT-JAKOB DISEASE (CJD). tissues in the palm of the hand, partly due to
rheumatic changes and partly to injury caused
Claudication by the constant pressure of a tool against the
A cramp-like pain that occurs in the legs on palm of the hand. (See DUPUYTRENS
walking. It may cause the sufferer to limp or, if CONTRACTURE.)
severe, stop him or her from walking. The
usual cause is narrowing or blockage of the Claw-Toes
arteries in the legs due to ATHEROSCLEROSIS: See CLAW-FOOT.
smoking is a contributary factor. Intermittent
claudication occurs when a person has to stop Cleft Foot
every so often to let the pain caused by the A rare congenital abnormality characterised by
build-up of waste products in the muscles to the absence of one or more toes and a deep
subside. The condition may be improved by central cleft that divides the foot into two. It is
exercise, for example, for an hour a day (resting sometimes known as lobster foot, or lobster
when the pain starts). Pentoxifylline, a vasodila- claw. It may be accompanied by other con-
tor, may help, as may CALCIUM-CHANNEL genital defects, such as CLEFT HAND, absent
BLOCKERS. Patients must avoid all tobacco permanent teeth, CLEFT PALATE (and/or lip),
products. absence of the nails, and defects of the eye.
 142 Cleft Hand

Cleft Hand only limited use because of its adverse effects;

A rare congenital abnormality characterised by patients should discontinue immediately if
the absence of one or more fingers and a deep diarrhoea or colitis develops.
central cleft that divides the hand into two. It is
sometimes known as lobster hand. It may be Clinical
C accompanied by other congenital defects, such Clinical means literally belonging to a bed,
as CLEFT FOOT, absent permanent teeth, CLEFT but the word is used to denote anything associ-
PALATE (and/or lip), absence of the nails and ated with the practical study or observation of
defects of the eye. sick people as in clinical medicine, clinical
thermometers.
Cleft Palate
A fissure in the roof of the mouth (palate) and/ Clinical Audit
or the lip which is present at birth. It is found A MEDICAL AUDIT carried out by health
in varying degrees of severity in about one in professionals.
700 children. Modern plastic surgery can
greatly improve the functioning of lips and Clinical Governance
palate and the appearance of the baby. Further A concept, introduced in a UK government
cosmetic surgery later may not be necessary. White Paper in 1997, aimed at ensuring that
The parent of the child who has cleft lip and/ all NHS organisations have in place proper pro-
or palate will be given detailed advice specific cesses for continuously monitoring and improv-
to his or her case. In general the team of spe- ing clinical audit. All clinicians and managers
cialists involved are the paediatrician, plastic are now expected to understand their individual
surgeon, dentist or orthodontic specialist, and and collective responsibilities for assuring
speech therapist. (See PALATE, MALFORMATIONS accountability for the quality of patient care.
OF.) Clinical governance is now included in the
NHS legislation based on the 1997 White
Clicking Finger Paper. (See also MEDICAL AUDIT; HEALTH CARE
A condition usually occurring in middle-aged COMMISSION; NATIONAL INSTITUTE FOR CLIN-
people in which the victim finds on wakening ICAL EXCELLENCE (NICE).)
in the morning that he or she cannot straighten
the ring or middle finger spontaneously, but Clinical Guidelines
only by a special effort, when it suddenly Systematically developed statements which
straightens with a painful click. Hence the assist clinicians and patients to decide on
name. In due course the finger remains bent at appropriate treatments for specific conditions.
all times unless a special effort is made to The guidelines are attractive to health managers
straighten it with the other hand. The condi- and patients because they are potentially able to
tion is due to a swelling developing in one of reduce variation in clinical practice. This helps
the tendons of the affected finger. If the tendon to ensure that patients receive the right treat-
sheath is slit open surgically, the condition is ment of an acceptable standard. In England and
relieved. Many cases recover spontaneously if Wales, the NATIONAL INSTITUTE FOR CLINICAL
the patient is prepared to wait. EXCELLENCE (NICE) is developing national
guidelines with advice from health-care profes-
Climacteric sionals and patients to improve clinical
This was a word originally applied to the end of effectiveness of NHS care. Some doctors have
certain epochs or stages in the life of an indi- reservations about guidelines because (1)
vidual, at which some great change was sup- health-care managers might use them primarily
posed to take place. (See also MENOPAUSE.) to contain costs; (2) inflexibility would discour-
age clinical innovations; (3) they could encour-
Clindamycin age litigation by patients. (See also HEALTH CARE
An antibiotic used in the treatment of serious COMMISSION; MEDICAL LITIGATION.)
infections. It is active against gram-positive
cocci, including penicillin-resistant staphylo- Clinical Psychology
cocci (see STAPHYLOCOCCUS) and also many Psychology is the scientific study of behaviour.
anaerobes (see ANAEROBE), especially Bacteroides It may be applied in various settings including
fragilis. It is recommended for staphylococcal education, industry and health care. Clinical
bone and joint infections such as OSTEO- psychology is concerned with the practical
MYELITIS and intra-abdominal sepsis, as well as application of research findings in the fields of
ENDOCARDITIS prophylaxis. Clindamycin has physical and mental health. Training in clinical
 Clinical Trials 143

psychology involves a degree in psychology fol- focused on organisational factors rather than
lowed by postgraduate training. Clinical psy- on the individuals involved in a specific case.
chologists are specifically skilled in applying
theoretical models and objective methods of Clinical Signs
observation and measurement, and in thera- The physical manifestations of an illness
peutic interventions aimed at changing elicited by a doctor when examining a patient C
patients dysfunctional behaviour, including for example, a rash, lump, swelling, fever or
thoughts and feelings as well as actions. Dys- altered physical function such as reflexes.
functional behaviour is explained in terms of
normal processes and modified by applying Clinical Symptoms
principles of normal learning, adaption and The experiences of a patient as communicated
social interaction. to a doctor, for example, pain, weakness, cough.
Clinical psychologists are involved in health They may or may not be accompanied by con-
care in the following ways: (1) Assessment of firmatory CLINICAL SIGNS.
thoughts, emotions and behaviour using stand-
ardised methods. (2) Treatment based on theor- Clinical Trials
etical models and scientific evidence about (See EVIDENCE-BASED MEDICINE.) Clinical trials
behaviour change. Behaviour change is con- aim to evaluate the relative effects of different
sidered when it contributes to physical, psycho- health-care interventions. They are based on
logical or social functioning. (3) Consultation the idea that there must a fair comparison of the
with other health-care professionals about prob- alternatives in order to know which is better.
lems concerning emotions, thinking and Threats to a fair comparison include the play of
behaviour. (4) Research on a wide variety of chance and bias, both of which can cause
topics including the relationship between stress, people to draw the wrong conclusions about
psychological functioning and disease; the aeti- how effective a treatment or procedure is.
ology of problem behaviours; methods and the- An appreciation of the need to account for
ories of behaviour change. (5) Teaching other chance and bias has led to development of
professionals about normal and dysfunctional methods where new treatments are compared
behaviour, emotions and functioning. to either a PLACEBO or to the standard treat-
Clinical psychologists may specialise in work ment (or both) in a controlled, randomised
in particular branches of patient care, including clinical trial. Controlled means that there is a
surgery, psychiatry, geriatrics, paediatrics, men- comparison group of patients not receiving
tal handicap, obstetrics and gynaecology, cardi- the test intervention, and randomised implies
ology, neurology, general practice and physical that patients have been assigned to one or
rehabilitation. Whilst the focus of their work is other treatment group entirely by chance and
frequently the patient, at times it may not because of their doctors preference. If
encompass the behaviour of the health-care possible, trials are double-blind that is, nei-
professionals. ther the patient nor the investigator knows
who is receiving which intervention until after
Clinical Risk Management the trial is over. All such trials must follow
Initially driven by anxiety about the possibility proper ethical standards with the procedure
of medical negligence cases, clinical risk fully explained to patients and their consent
management has evolved into the study of obtained.
IATROGENIC DISEASE. The first priority of risk The conduct, effectiveness and duplication
managers is to ensure that all therapies in medi- of clinical trials have long been subjects of
cine are as safe as possible. Allied to this is a debate. Apart from occasional discoveries of
recognition that errors may occur even when deliberately fraudulent research (see RESEARCH
error-prevention strategies are in place. Lastly, FRAUD AND MISCONDUCT), the structure of
any accidents that occur are analysed, allowing some trials are unsatisfactory, statistical analyses
a broader understanding of their cause. Risk are sometimes disputed and major problems
management is generally centred on single have been the usually unwitting duplication
adverse events. The threat of litigation is taken of trials and non-publication of some trials,
as an opportunity to expose unsafe conditions restricting access to their findings. Duplication
of practice and to put pressure on those with occurs because no formal international mechan-
the authority to implement change. These ism exists to enable research workers to discover
might include senior clinicians, hospital man- whether a clinical trial they are planning is
agement, the purchasing authorities, and even already underway elsewhere or has been com-
the Secretary of State for Health. Attention is pleted but never published, perhaps because the
 144 Clitoris

results were negative, or no journal was willing Clomipramine

to publish it, or the authors or funding author- One of the tricyclic ANTIDEPRESSANT DRUGS.)
ities decided not to submit it for publication.
In the mid 1980s a proposal was made for an Clonazepam
international register of clinical trials. In 1991 A drug to treat EPILEPSY, including STATUS
C the NHS launched a research and development EPILEPTICUS, and MYOCLONUS. (See also
initiative and, liaising with the COCHRANE TRANQUILLISERS.)
COLLABORATION, set out to collect systematic-
ally data from published randomised clinical Clone
trials. In 1994 the NHS set up a Centre for A group of cells genetically identical to each
Reviews and Dissemination which, among other that have arisen from one cell by asexual
other responsibilities, maintains a database of reproduction (see CLONING).
research reviews to provide NHS staff with rele-
vant information. Clonic
These efforts are hampered by availability of A word applied to short spasmodic movements.
information about trials in progress and
unpublished completed trials. With a view to Clonidine
improving accessibility of relevant information, A drug used forHYPERTENSION, MIGRAINE,
the publishers of Current Science, in 1998, GILLES DE LA TOURETTES SYNDROME, and
launched an online metaregister of ongoing menopausal flushing. It can cause drowsiness so
randomised controlled trials. caution is needed when driving or using
Subsequently, in October 1999, the editors machinery.
of the British Medical Journal and the Lancet
argued that the case for an international register Cloning
of all clinical trials prior to their launch was Cloning from the Greek klon, meaning a cut-
unanswerable. The public, they said, has the ting such as is used to propagate plants is
right to know what research is being funded. essentially a form of asexual reproduction. The
Researchers and research funders dont want initial stages were first successfully achieved in
to waste resources repeating trials already rabbits. In essence the technique consists of des-
underway. Given the widening recognition of troying the nucleus of the egg and replacing it
the importance to patients and doctors of the with the nucleus from a body cell of the same
practice of EVIDENCE-BASED MEDICINE, the species either a male or a female. This pro-
easy availability of information on planned, vides the egg with a full complement of CHRO-
ongoing and completed clinical trials is vital. MOSOMES and it starts to divide and grow just
The register was finally set up in 2005. as it would if it had retained its nucleus and
been fertilised with a spermatozoon. The vital
Clitoris difference is that the embryo resulting from this
A small, sensitive organ comprising erectile tis- cloning process owes nothing genetically to the
sue at the top of the female genitalia where the female egg. It is identical in every respect with
labial folds meet below the pubic bone. Clitoral the animal from which the introduced nucleus
tissue extends into the anterior roof of the was obtained.
vagina. During sexual excitement the clitoris In 1997 the first mammal to be cloned from
enlarges and hardens and may be the focus of the tissue of an adult animal was born. A tech-
orgasm. (See CIRCUMCISION.) nique that scientists have been trying to perfect
for decades, the success of the Roslin Institute,
Clofazimine near Edinburgh, in producing Dolly, a cloned
A drug used in the treatment of LEPROSY. sheep, has profound implications. Already some
scientists are talking of cloning humans,
Clofibrate although this has great medical, legal and eth-
See HYPERLIPIDAEMIA. ical consequences. The key to the scientists
success in producing Dolly was the ability to
Clomiphene coordinate the fusion of a donor cell (from an
An anti-oestrogen drug that stimulates ovula- adult) containing all its DNA with a recipient
tion, or the production of ova, through the egg from which DNA had been removed. The
medium of the PITUITARY GLAND. When used difficulty of the technique is shown by the fact
in the treatment of female infertility, one of its that, out of 277 fused pairs of cells where the
hazards is that, if given in too-big doses, it may donor cell was from adult tissue, Dolly was the
produce multiple births. only survivor and she has developed premature
 Cluster Headaches 145

arthritis. Research suggests that cloning may be diseased vessels (THROMBOSIS), producing ser-
accompanied by a higher than normal inci- ious effects upon the tissues supplied or drained
dence of congenital defects. by these vessels. Clots sometimes form in the
Since Dolly was born, other animal clones heart when the circulation is failing. (See
have been produced and American researchers COAGULATION; EMBOLISM.)
have cloned the first human embryo which C
grew to six cells with the aim of providing Clotrimazole
stem cells for therapeutic use. As a result the A drug of the IMIDAZOLES group used to treat
UK government passed emergency legislation fungal infections of the skin and vagina.
to outlaw human cloning for reproductive
purposes. Clotting Time
See COAGULATION.
Clonus
A succession of intermittent muscular relaxa- Clozapine
tions and contractions usually resulting from a An antipsychotic drug used to treat schizo-
sustained stretching stimulus. An example is the phrenic patients (see SCHIZOPHRENIA) who
clonus stimulated in the calf muscle by main- have not responded to other treatments or
taining sustained upward pressure on the sole of who have suffered serious side-effects from
the foot. The condition is often a sign of disease them. Improvement is gradual and it may be
in the brain or spinal cord. several weeks before severe symptoms are
relieved. The drug can cause AGRANULOCYTO-
Clormethiazole SIS and so it is given under close hospital
A useful hypnotic, particularly for elderly supervision.
patients, because of its freedom from hangover
effect. It is especially beneficial in the acute Clubbing
withdrawal symptoms of alcoholism and is used The term applied to the thickening and broad-
to treat STATUS EPILEPTICUS. The drugs seda- ening of the fingertips and, less commonly,
tive effects are an adjunct to regional anaes- the tips of the toes that occurs in certain
thesia and may also be of help in ECLAMPSIA. chronic diseases of the lungs and heart. It is due
Dependence may occur occasionally and there- to interstitial OEDEMA especially at the nail bed,
fore the length of period for which the drug is leading to a loss of the acute angle between the
used should be limited. Side-effects include nail and the skin of the finger. Clubbing is
sneezing, conjunctival irritation and occasional associated with lung cancer, EMPYEMA, BRON-
headache. CHIECTASIS and congenital cyanotic heart
disease.
Clostridium
The genus, or variety, of micro-organisms that Club-Foot
produce spores which enable them to survive See TALIPES.
under adverse conditions. They normally grow
in soil, water and decomposing plant and ani- Cluster
mal matter, where they play an important part In statistical terms a group of subjects, closely
in the process of PUTREFACTION. Among the linked in time and/or place of occurrence. For
important members of the group, or genus, are example, geographical clusters of LEUKAEMIA
Clostridium welchii, Cl. septicum and Cl. oede- have been found that is, an unexpectedly large
matiens, the causes of gas gangrene (see GAN- number of persons with the disease who live in
GRENE); Cl. tetani, the cause of TETANUS; and close proximity. Much research goes into trying
Cl. botulinum, the cause of BOTULISM. to discover the cause of clusters but sometimes
they appear to have occurred randomly.
Clot
The term applied to any semi-solid mass of Cluster Headaches
blood, lymph or other body fluid. Clotting in A type of MIGRAINE occurring in clusters that
the blood is due to the formation of strings of is, a patient may have an attack daily for several
FIBRIN produced by the action of a ferment. days and then none for weeks or months. The
Milk clots in a similar manner in the stomach pain is on one side of the head, often centred
when exposed to the action of the enzyme ren- over the eye. The pain is excruciatingly severe
nin. Clotting occurs naturally when blood is and often associated with tearing, nasal dis-
shed and comes into contact with tissues out- charge and production of thick saliva from the
side the blood vessels. It occurs also at times in same side of the mouth. It is treated either with
 146 CMV

drugs such as SUMATRIPTAN or by breathing stance present in the blood in small amounts,
100 per cent oxygen. and that this substance antagonises any small
amounts of thrombin that may be formed as a
CMV result of small amounts of thromboplastin
See CYTOMEGALOVIRUS (CMV). being released.
C The clotting or coagulation time is the time
Coagulation taken for blood to clot and can be measured
Coagulation of the blood is the process whereby under controlled conditions to ensure that it is
bleeding (or haemorrhage) is normally arrested normal (38 minutes). In certain diseases
in the body. Blood starts to clot as soon as the HAEMOPHILIA, for example clotting time is
skin (or other tissue) has been cut. Coagulation greatly extended and the danger of serious
is part of the process of HAEMOSTASIS which is haemorrhage enhanced.
the arrest of bleeding from an injured or dis-
eased blood vessel. Haemostasis depends on the Coagulopathy
combined activities of vascular, platelet (see Any disorder affecting the coagulability of
PLATELETS) and PLASMA elements which are off- blood (see COAGULATION). Among acute condi-
set by processes to restrict the accumulation of tions precipitating the disorder are ABRUPTIO
platelets and FIBRIN to the damaged area. PLACENTA, HAEMOLYSIS following blood trans-
The three-stage process of coagulation is fusions, infection with gram-negative bacteria
complex, involving many different substances. (see GRAMS STAIN), HEAT STROKE, SHOCK and
There are two cascading pathways of bio- snakebite. Chronic disorders linked with coagu-
chemical reactions for activating coagulation of lopathy are septic ABORTION, TOXAEMIA of
blood. The extrinsic pathway is the main pregnancy, certain cancers and LEUKAEMIA.
physiological mechanism, which is triggered
when blood vessels are damaged, usually by Coarctation of the Aorta
trauma or surgery. The intrinsic pathway is A narrowing of the AORTA in the vicinity of the
activated by internal disruption of the wall of a insertion of the ductus arteriosus. It is a con-
blood vessel. The basic pattern is broadly the genital abnormality but may not be discovered
same for both and is summarised simply as until well into childhood or adolescence. The
follows: diagnosis is easily made by discovering a major
prothrombin + calcium + thromboplastin difference between the blood pressure in the
thrombin + fibrinogen arms and that of the legs. If untreated it leads to
fibrin hypertension and heart failure, but satisfactory
Prothrombin and calcium are normally pres- results are now obtained from surgical treat-
ent in the blood. Thromboplastin is an enzyme ment, preferably in infancy. Paediatricians
which is normally found in the blood platelets screen for coarctation by feeling for femoral
and in tissue cells. When bleeding occurs from pulses, which are absent or weak in this
a blood vessel, there is always some damage to condition.
tissue cells and to the blood platelets. As a result
of this damage, thromboplastin is released and Cobalamins
comes into contact with the prothrombin and A group of substances which have an enzyme
calcium in the blood. In the presence of throm- action (see ENZYME) and are essential for normal
boplastin and calcium, prothrombin is con- growth and nutrition. (See also CYANOCOBAL-
verted into thrombin, which in turn interacts AMIN; HYDROXOCOBALAMIN.)
with fibrinogen a protein always present in
the blood to form fibrin. Fibrin consists of Cobalt-60
needle-shaped crystals which, with the assist- Cobalt-60 is a radioactive isotope of the metal-
ance of the blood platelets, form a fine network lic element cobalt (Co). It is used in the treat-
in which the blood corpuscles become ment of malignant disease. (See
enmeshed. This meshwork, or CLOT as it is RADIOTHERAPY.)
known, gradually retracts until it forms a tight
mass which, unless the tissue injury is very Cocaine
severe or a major artery has been damaged, pre- Coca leaves are obtained from two South Amer-
vents any further bleeding. It will thus be seen ican plants, Erythroxylum coca and Erythroxylum
that clotting, or coagulation, does not occur in truxillense, and contain an alkaloid, cocaine.
the healthy blood vessel because there is no Cocaine has marked effects as a stimulant, and,
thromboplastin present. There is now evidence locally applied, as an anaesthetic by paralysing
suggesting that there is an anti-thrombin sub- nerves of sensation. The dried leaves have been
 Cod-Liver Oil 147

used from time immemorial by the South hearing in profound sensory deafness. Although
American Indians, who chew them mixed with there are many types of cochlear implant, they
a little lime. Their effect is to dull the mucous all consist of a microphone, a signal processor, a
surfaces of mouth and stomach, with which the signal coupler (transmitter and receiver), and an
saliva, produced by chewing them, comes into array of electrodes. Most are multi-channel
contact thus blunting, for long periods, all implants. The microphone and signal processor C
feeling of hunger. The cocaine, being absorbed, are worn outside the body, like a conventional
stimulates the central nervous system so that all hearing aid: they receive sound and convert it
sense of fatigue and breathlessness vanishes for a into an electronic signal which is transmitted
time. It was by the use of coca that the Indian through the skin to the receiver. Here the signal
post-runners of South America were able to is transmitted to the array of electrodes which
achieve their extraordinary feats of endurance. stimulates the cochlear nerve. Although coch-
The continued use of the drug, however, results lear implants do not provide normal hearing,
in emaciation, loss of memory, sleeplessness and most profoundly deaf patients who receive a
general breakdown. DEPENDENCE on cocaine or cochlear implant are able to detect a variety of
a derivative, crack, is now a serious social prob- sounds, including environmental sounds and
lem in many countries. speech. The duration of hearing-loss and age at
implantation are among the many factors
Uses Before the serious effects that result which influence the results (see DEAFNESS).
from its habitual use were realised, the drug was
sometimes used by hunters, travellers and Cochrane Collaboration
others to relieve exhaustion and breathlessness A non-profit-making international organisation
in climbing mountains and to dull hunger. which systematically finds, appraises and
Derivatives of cocaine are used as locally reviews available evidence, mainly from ran-
applied analgesics via sprays or injections in domised CLINICAL TRIALS, about the con-
dentistry and for procedures in the ear, nose sequences of health care. The aim is to help
and throat. Because of its serious side-effects people make well-informed decisions about
and the risk of addiction, cocaine is a strictly health care. The main work is done by around
controlled Class A drug which can be pre- 50 review groups, the members of which share
scribed only by a medical practitioner with a an interest in generating reliable, up-to-date
Home Office licence to do so. evidence on the prevention, treatment and
rehabilitation of particular health problems or
Cocci groups of problems. The UK Cochrane Centre
Spherical BACTERIA that cause a variety of infec- opened in Oxford in 1992 and the Inter-
tions. Staphylococci, streptococci and menin- national Collaboration launched a year later. Its
gococci (see NEISSERIACEAE) are examples. origins lay in the work of a UK epidemiologist,
Dr Archie Cochrane, who in 1979 published a
Coccydynia monograph calling for a systematic collection of
The sensation of severe pain in the COCCYX. randomised controlled trials on the effect of
health care.
Coccyx The main output of the Cochrane Collabor-
The lower end of the SPINAL COLUMN, resem- ation is published electronically as the
bling a birds beak and consisting of four fused Cochrane Library, updated quarterly, with free
nodules of bone; these represent vertebrae and access in many countries. (See CLINICAL TRIALS,
correspond to the tail in lower animals. Above EVIDENCE-BASED MEDICINE and Appendix 2.)
the coccyx lies a much larger bone, the SACRUM,
and together they form the back wall of the Codeine
PELVIS, which protects the organs in the lower One of the active principles of OPIUM, codeine
ABDOMEN. is an analgesic (see ANALGESICS) which in the
form of codeine phosphate is used to suppress
Cochlea persistent coughs and to relieve pain such as
That part of the inner ear concerned with hear- headaches and musculoskeletal discomfort.
ing. (See EAR.) Side-effects include constipation, nausea and
sleepiness. Dependence is rare.
Cochlear Implants
A cochlear implant is an electronic device, Cod-Liver Oil
inserted under a general anaesthetic, which Cod-liver oil is derived from the fresh liver of
stimulates the auditory system, restoring partial the cod (Gadus callarius). It is a rich source of
 148 Coeliac Disease

vitamin D, used in the prevention and treat- The key treatment is a strict, lifelong diet
ment of RICKETS, and of vitamin A. Human free of gluten. As well as returning the bowel
milk contains more than enough vitamin D for lining to normal, this diet results in a return
the breast-fed baby, provided the mother has a to normal bone density. People with coeliac
balanced diet with adequate exposure to sun- disease, or parents or guardians of affected
C light, or is taking vitamin supplements during children, can obtain help and guidance
pregnancy and lactation if considered necessary. from the Coeliac Society of the United King-
All baby foods in the UK contain added vit- dom. (See also MALABSORPTION SYNDROME;
amins, and therefore supplementation is SPRUE.)
unnecessary until weaning begins, and the baby
starts taking cows milk, which contains less Coelioscopy
vitamin D than human milk. (See APPENDIX 5: A method of viewing the interior of the abdo-
VITAMINS.) men in patients in whom a tumour or some
other condition requiring operation may be
Coeliac Disease present but cannot with certainty be diagnosed.
Around one in 100 people suffers from coeliac The examination is carried out by making a
disease, a condition in which the small INTES- minute opening under local anaesthesia, and
TINE fails to digest and absorb food, but many inserting an ENDOSCOPE a long flexible
have no or few symptoms and remain instrument bearing an electric lamp and tele-
undiagnosed. The intestinal lining is perman- scopic lenses like that for examining the bladder
ently sensitive to the protein gliadin (an insol- (CYSTOSCOPE) into the abdominal cavity.
uble and potentially toxic PEPTIDE protein) Certain of the abdominal organs can then be
which is contained in GLUTEN, a constituent of directly inspected in turn.
the germ of wheat, barley and rye. As bread or
other grain-based foods are a regular part of Cognition
most peoples diet, the constant presence of The mental processes by which a person
gluten in the intestine of sufferers of coeliac acquires knowledge. Among these are reason-
disease causes atrophy of the digestive and ing, creative actions and solving problems.
absorptive cells of the intestine. Children are
usually diagnosed when they develop symp- Cognitive Behaviour Therapy
toms such as vomiting, diarrhoea, lethargy, A talking therapy that re-trains the mind to
ANAEMIA, swollen abdomen and pale, frothy, question and banish negative thoughts, change
foul-smelling faeces with failure to thrive. The emotional responses and change behaviour. It is
diagnosis is usually made by a positive blood based on the theory that some people develop
antibody test such as antiendomysial anti- unduly negative and pessimistic thoughts (cog-
bodies. However, because there may be an nitions) about themselves, their future and the
occasional false positive result, the gold stand- world around them, putting them at risk of
ard is to obtain a biopsy of the JEJUNUM depression and other mental-health problems.
through a tiny metal capsule that can be swal- Put simply, the treatment involves several ses-
lowed, a specimen taken, and the capsule sions with a trained therapist who helps to iden-
retrieved. Though coeliac disease was long tify the negative patterns of thinking and show
thought to occur in childhood, a second peak that they are not usually realistic.
of the disorder has recently been identified Research has shown that cognitive therapy
among people in their 50s. is very effective in depression and that it can
Not all sufferers from coeliac disease present also help in anxiety, OBSESSIVE COMPULSIVE
with gastrointestinal symptoms: doctors, using DISORDER, and EATING DISORDERS such as
screening techniques, have increasingly identi- anorexia and bulimia nervosa. This therapy
fied large numbers of such people. This is is also proving useful in helping people cope
important because researchers have recently dis- with HALLUCINATIONS and other symptoms of
covered that untreated overt and silent coeliac SCHIZOPHRENIA.
disease increases the risk of sufferers developing
osteoporosis (brittle bone disease see BONE, Cohort Study
DISORDERS OF) and cancer. The osteoporosis A systemised follow-up study of people for a
develops because the bowel fails to absorb the specific period of time, or until the occurrence
CALCIUM essential for normal bone growth. of a defined event such as a particular illness or
Because those with coeliac disease lack the death. The aim is to follow the disease course
enzyme LACTASE, which is essential for digesting and/or the reasons for the participants deaths.
milk, they avoid milk a rich source of calcium. Different cohorts may be compared and con-
 Cholestyramine 149

clusions drawn about a particular disease or such as asthma, bronchitis or ear infections.
drug treatment. Most colds are self-limiting, resolving in a week
or ten days, but some patients develop second-
Coitus ary bacterial infections of the sinuses, middle
Coitus is sexual intercourse. ear (see EAR), trachea, or LUNGS.
C
Coitus interruptus (see CONTRACEPTION). Treatment Symptomatic treatment with
ANTIPYRETICS and ANALGESICS is usually
Colchicine sufficient; ANTIBIOTICS should not be taken
A drug used to treat GOUT in the acute stage. Its unless there is definite secondary infection or
use is limited by the development of toxicity at unless the patient has an existing chest condi-
higher doses, but in patients with heart failure it tion which could be worsened by a cold. Cold
may be preferable to NON-STEROIDAL ANTI- victims should consult a doctor only if symp-
INFLAMMATORY DRUGS (NSAIDS), which tend to toms persist or if they have a pre-existing condi-
cause fluid retention. Colchicine can be given tion, such as asthma which could be exacer-
to patients receiving ANTICOAGULANTS. The bated by a cold.
drug does have side-effects on the gastrointest- Most colds result from breathing-in virus-
inal system. containing droplets that have been coughed or
sneezed into the atmosphere, though the virus
Colchicum can also be picked up from hand-to-hand con-
The bulb of Colchicum autumnale, or meadow- tact or from articles such as hand towels. Pre-
saffron, has long been used as a remedy for vention is, therefore, difficult, given the high
GOUT. How it acts is not quite certain. infectivity of the viruses. No scientifically
proven, generally applicable preventive meas-
Uses Its main use is in gout, for which colchi- ures have yet been devised, but the incidence of
cine, the active principle of colchicum, in doses the infection falls from about seven to eight
of 05 mg every one or two hours until the pain years schoolchildren may catch as many as
is relieved, followed by 05 mg thrice daily for eight colds annually to old age, the elderly
about a week, is the form generally employed. having few colds. So far, despite much research,
no effective vaccines have been produced.
Cold, Common
An infection by any one of around 200 viruses, Cold, Injuries from
with about half the common-cold infections See CHILBLAIN; FROSTBITE; HYPOTHERMIA.
being caused by RHINOVIRUSES. Certain
CORONAVIRUSES, ECHOVIRUSES and COXSACKIE Cold Sores
VIRUSES are also culprits. The common cold See HERPES SIMPLEX.
traditionally also called a chill is one of several
viral infections that cause respiratory symptoms Cold-Weather Itch
and systemic illness. Others include PNEU- Cold-weather itch is a common form of
MONIA and GASTROENTERITIS. Colds are com- itchiness that occurs in cold weather. It is char-
moner in winter, perhaps because people are acterised by slight dryness of the skin, and is
more likely to be indoors in close contact with particularly troublesome in the legs of old
others. people. The dryness may be accompanied by
Also called acute coryza or upper respiratory some mild inflammation of the skin. Treat-
infection, the common cold is characterised by ment is by the application of emollients such as
inflammation of any or all of the airways aqueous cream or zinc ointment.
NOSE, sinuses (see SINUS), THROAT, LARYNX,
TRACHEA and bronchi (see BRONCHUS). Most Colectomy
common, however, is the head cold, which is The operation for removing the COLON.
confined to the nose and throat, with initial
symptoms presenting as a sore throat, runny Cholestyramine
nose and sneezing. The nasal discharge may A drug of value in the treatment of the PRUR-
become thick and yellow a sign of secondary ITUS, or itching, which occurs in association
bacterial infection while the patient often with JAUNDICE. It does this by binding the
develops watery eyes, aching muscles, a cough, bile salts in the gut and so preventing their
headache, listlessness and the shivers. PYREXIA being reabsorbed into the bloodstream, where
(raised temperature) is usual. Colds can also their excess in jaundice is responsible for the
result in a flare-up of pre-existing conditions, itching. It reduces the level of cholesterol and
 150 Colic

triglycerides in the blood and thereby, like Colistin

clofibrate and STATINS, helping to reduce the A POLYMYXIN antibiotic active against many
incidence of coronary artery heart disease. (See gram-negative organisms, including Pseu-
HEART, DISEASES OF; HYPERLIPIDAEMIA.) domonas aeruginosa. It is not absorbed by
mouth and therefore needs to be given by injec-
C Colic tion to obtain a systemic effect; this is rarely
This term is generally used for an attack of indicated, however, as it has serious adverse
spasmodic pain in the abdomen. effects. Colistin is used by mouth in bowel-
sterilisation regimens before surgery in
Simple colic often results from the build-up patients. It is given by inhalation of a nebulised
of indigestible material in the alimentary tract, solution as an adjunct to some standard anti-
leading to spasmodic contractions in the mus- biotic therapy, and is included in some topical
cular lining. Other causes include habitual con- preparations, chiefly for skin, eye and ear
stipation, with accumulation of faecal material; infections.
simple colic also occurs as an accompaniment
of neurological disorders. Major risks include Colitis
sudden obstruction of the bowel from twisting, Inflammation of the colon, the first part of the
INTUSSUSCEPTION, or as a result of a tumour or large intestine. The subject suffers from diar-
similar condition. (See also INTESTINE, DISEASES rhoea, usually passing blood and mucus,
OF.) abdominal pain or discomfort, and fever. Col-
itis can be caused by various micro-organisms:
Lead colic (traditional names include paint- for example, CAMPYLOBACTER, CLOSTRIDIUM
ers colic, colica pictonum, Devonshire colic, and SHIGELLA bacteria, viruses or amoeba. Anx-
dry belly-ache) is due to the absorption of lead iety and antibiotic drugs may also cause colitis,
into the system. (See LEAD POISONING.) the latter by directly irritating the lining of the
gut.
Biliary colic and renal colic are the Colitis is classified as an INFLAMMATORY
terms applied to that violent pain which is BOWEL DISEASE (IBD) and ULCERATIVE COLITIS
produced, in the one case where a biliary calcu- is a particularly troublesome form, the cause of
lus or gall-stone passes down from the gall- which is not known. CROHNS DISEASE may also
bladder into the intestine, and in the other cause colitis and is included in the umbrella
where a renal calculus descends from the kid- designation IBD (see also IRRITABLE BOWEL
ney along the ureter into the bladder. (See SYNDROME (IBS)).
GALL-BLADDER, DISEASES OF and KIDNEYS, DIS-
EASES OF.) Collagen
The most abundant protein in the body. It is
Treatment This consists of means to relieve the major structural component of many parts
the spasmodic pain with warmth and of the body and occurs in many different forms.
analgesics, and removal, where possible, of the Thus it exists as thick fibres in skin and ten-
underlying cause. dons. It is also an important constituent of the
heart and blood vessels. With calcium salts it
Infantile colic is a common condition in provides the rigid structure of bone. It also
babies under three months, sometimes continu- occurs as a delicate structure in the cornea of
ing for a little longer. The babies cry persist- the eye, and in what is known as the basement
ently and appear to their parents to have membrane of many tissues including the glom-
abdominal pain, although this remains eruli of the kidneys and the capsule of the lens
unproven. Swaddling and massage can help, as of the eye. It plays a part in many diseases, her-
can simply stimulating the child with move- editary and otherwise. Among the inherited
ment and noise (rocking and singing). Medica- abnormalities of collagen are those responsible
tion is usually unhelpful, although the most for aneurysms of the CIRCLE OF WILLIS and for
severely affected deserve help because of the OSTEOGENESIS IMPERFECTA. On boiling it is
deleterious effect of infantile colic on family converted into gelatin.
life.
Collagen Diseases
Coliform A group of diseases affecting CONNECTIVE TIS-
Description of a gram-negative bacterium SUE. The term is really outdated since there is
found in the faeces. It covers the bacterial no evidence that collagen is primarily involved.
groups Enterobacter, Escherichia, and Klebsiella. Fibrinoid NECROSIS and VASCULITIS are two
 Colposcopy 151

characteristics, and autoimmunity reaction Colonoscope

may occur in the connective tissue. The latter An ENDOSCOPE for viewing the interior of the
affects blood vessels and causes secondary dam- COLON. It is made of fibreglass which ensures
age in the connective tissue. Such conditions flexibility, and incorporates a system of lenses
are sometimes described as collagen vascular for magnification and a lighting system.
diseases, examples being RHEUMATOID ARTH- C
RITIS, SYSTEMIC LUPUS ERYTHEMATOSUS (SLE), Colonoscopy, Virtual
and SCLERODERMA. A procedure that links COMPUTED TOM-
OGRAPHY of the COLON (see also INTESTINE) with
Collapse techniques that produce three-dimensional
See SHOCK. views of the mucosa of the large bowel similar to
those obtained during traditional colonoscopy.
Collar-Bone Early experience suggests that the new tech-
See CLAVICLE. nique produces better results than barium
enemas (see ENEMA) and is almost as effective as
Colles Fracture conventional colonoscopy. Virtual colonoscopy
Colles fracture is a fracture of the lower end of offers faster results, and image analysis will
the radius close to the wrist, caused usually by a probably soon be automated. The procedure is
fall forwards on the palm of the hand, in which easy, non-invasive, safe and complete; once the
the lower fragment is displaced backwards. (See need for bowel cleansing is eliminated (as seems
BONE, DISORDERS OF.) likely) it will provide a prominent tool in screen-
ing for cancer of the colon and RECTUM.
Collodions
Collodions consist basically of a thick, colour- Colostomy
less, syrupy liquid, made by dissolving gun- The operation for the establishment of an arti-
cotton (pyroxylin) in a mixture of ether and ficial opening into the COLON. This acts as an
alcohol or with acetone. When painted on the artificial ANUS. The operation is carried out
skin the solvent evaporates, leaving behind a when there is an obstruction in the colon or
tough protective film that is useful for covering rectum that cannot be overcome, or in cases
wounds. Flexible collodion or collodion as it such as cancer of the rectum in which the rec-
is often known contains 16 per cent of pyr- tum and part of the colon have to be removed.
oxylin, with colophony, castor oil and alcohol A colostomy opening can be trained to function
(90 per cent) in solvent ether. It should be kept in such a way that the patient can carry on a
in a well-sealed container. Being relatively elas- normal life, eating a more or less normal diet.
tic, it does not crack through the movements of Anyone desiring help or advice in the practical
the skin. management of a colostomy should get in
touch with the British Colostomy Association.
Colloid (See also STOMA.)
A type of suspension, for instance milk, in
which insoluble particles are suspended in a Colostrum
fluid. In medical parlance a colloid prepar- The first fluid secreted by the mammary glands
ation is one containing PLASMA proteins and is for two or three days after childbirth. It con-
used to treat patients in SHOCK. The follicles tains less CASEIN and more albumin (see ALBU-
of the thyroid gland also contain a colloid MINS) than ordinary milk.
substance.
Colour Blindness
Coloboma See VISION Defective colour vision.
Coloboma simply means a defect, but its use is
usually restricted to congenital defects of the Colporrhaphy
eye. These may involve the lens, the iris, the An operation designed to strengthen the pelvic
retina or the eyelid. floor in cases of prolapse of the UTERUS. The
surgeon excises redundant tissue from the front
Colon vaginal wall (anterior colporrhaphy) or from
The first part of the large INTESTINE. the rear wall (posterior colporrhaphy), thus nar-
rowing the vagina and tightening the muscles.
Colonic Irrigation
Washing out the large bowel with an ENEMA of Colposcopy
water or other medication. The method of examining the VAGINA and
 152 Coma

CERVIX UTERI by means of the binocular AGENCY in the UK on the safety, efficacy and
instrument known as the colposcope. It is used pharmaceutical quality of MEDICINES for which
to screen for cancer of the cervix and in investi- licences are sought and also reviews reports of
gation of child sexual abuse. ADVERSE REACTIONS TO DRUGS, including
spontaneous Yellow Card reports from doctors
C Coma or pharmacists who suspect that a patient has
A state of profound unconsciousness in which suffered an adverse reaction from a medicine.
the patient cannot be roused and reflex move- Its predecessor, the Committee for Safety of
ments are absent. Signs include long, deep, Drugs, was set up in 1963 in response to the
sighing respirations, a rapid, weak pulse, and THALIDOMIDE disaster.
low blood pressure. Usually the result of a
STROKE, coma may also be due to high fever, Common Cold
DIABETES MELLITUS, glomerulonephritis (see See COLD, COMMON.
KIDNEYS, DISEASES OF), alcohol, EPILEPSY, cere-
bral TUMOUR, MENINGITIS, injury to the head, Communicable Disease
overdose of INSULIN, CARBON MONOXIDE (CO) This is an infectious or contagious disease
poisoning, or poisoning from OPIUM and other which can be passed from one person to
NARCOTICS. Though usually of relatively short another. Direct physical contact, the handling
duration (and terminating in death, unless of an infected object, or the transfer by droplets
yielding to treatment) it may occasionally last coughed or breathed out are all ways in which
for months or even years. (See UNCONSCIOUS- micro-organisms can be transmitted. The gov-
NESS; GLASGOW COMA SCALE.) ernment produces a list of NOTIFIABLE DIS-
EASES, which includes all the dangerous com-
Coma Position municable diseases from anthrax, cholera and
See RECOVERY POSITION and APPENDIX 1: BASIC diphtheria through meningitis, rabies and
FIRST AID. smallpox to typhoid fever and whooping-cough
(see respective entries). The UKs Public Health
Coma Scale (Control of Diseases) Act 1984 and subsequent
See GLASGOW COMA SCALE. regulations in 1988 oblige a doctor who sus-
pects that a patient has a notifiable disease to
Comedones report this to the local consultant in com-
See ACNE. municable disease. Expert support is provided
by the Public Health Laboratory Service via
Commensal surveillance centres and specialist laboratories.
Micro-organisms which live in or on the body
(e.g. in the gut or respiratory tract, or on the Communicable Diseases Control
skin) without doing any harm to the individual. The control of disease caused by infectious
agents or their toxic products. Successes in the
Comminuted Fracture 19th and 20th centuries in the treatment and
See BONE, DISORDERS OF. control of communicable diseases such as
SMALLPOX, CHOLERA, TUBERCULOSIS, gastro-
Commission for Health intestinal infections, POLIOMYELITIS and SEXU-
Improvement ALLY TRANSMITTED DISEASES (STDS) resulted in
See HEALTHCARE COMMISSION. an erroneous conception that they no longer
posed a serious threat to public health, and cer-
Commissure tainly not in developed countries. As a con-
Commissure means a joining, and is a term sequence, the maintenance of effective public
applied to strands of nerve fibres which join one health strategies steadily lost out in the competi-
side of the brain to the other; to the band join- tion for resources to the more glamorous devel-
ing one optic nerve to the other; to the junc- opments in medicine, such as improved CANCER
tions of the lips at the corners of the mouth, etc. treatments, HEART surgery, kidney DIALYSIS and
organ TRANSPLANTATION. However, in recent
Committee on Safety of decades the dangers of this approach have
Medicines (CSM) become increasingly apparent. Rapidly expand-
An independent advisory committee ing urban populations, more complex lifestyles,
launched in 1971 in the United Kingdom new and resurgent infections (some linked to a
composed of doctors, pharmacists and other spread of antibiotic resistance) such as AIDS/HIV
specialists. It advises the MEDICINES CONTROL and variant CREUTZFELDT-JAKOB DISEASE (CJD),
 Community Mental Health Teams 153

and the ease with which infection can be spread ation of the services of an often large number of
by the enormous growth of long-distance providers from the health and social-services
travel and population migrations are severely sectors. Poor communication between sectors
straining existing public health measures. The and inadequate coordination of services have
supply of clean water, effective waste- and been among the most common complaints
sewage-disposal measures, the hygienic produc- about the community-care reforms. C
tion and delivery of food and early detection Health care for people being cared for in the
and subsequent prevention of infectious dis- community remains largely free under the NHS
eases can no longer be taken for granted. Gov- arrangements, although there are regular
ernments will need to strengthen the provision debates about where the boundaries should be
of workable, properly resourced public health drawn between free health services and means-
facilities, and developing countries will need tested social care. A distinction has been made
financial support and expert help from between necessary nursing care (funded by the
developed nations to achieve this objective. state) and normal personal care (the responsibil-
Timely recognition of new and resurgent infec- ity of the patient), but the dividing line often
tious diseases requires national and inter- proves hard to define.
national early-warning mechanisms to ensure As care has shifted increasingly into the
rapid investigation and implementation of community, previous hospital facilities have
effective control measures. Otherwise, serious become redundant. Vast numbers of beds in
breakdowns in public health will occur, and long-stay geriatric hospitals and in-patient psy-
international co-operation is vital to provide chiatric wards have been closed. There is now
and support control measures. (See also COM- concern that too few beds remain to provide
MUNICABLE DISEASE; NOTIFIABLE DISEASES.) essential emergency and respite services. In
some areas, patients fit for discharge are kept in
Community Care hospital because of delay in setting up com-
Community care is intended to enable people munity services for the elderly, or because of the
to lead independent lives at home or in local inability of the local authority to fund
residential units for as long as they are able to appropriate care in a nursing home or at home
do so. For many years there has been a trend in with community-care support for other
Britain for care of elderly people and those with patients; the resulting BED-BLOCKING has an
mental or physical problems to be shifted from adverse effect on acutely ill patients needing
hospitals and into community settings. In 1988 hospital admission.
Sir Roy Griffithss report to the Secretaries of Community care, if correctly funded and
State for Social Services, Community Care: coordinated, is an excellent way of caring for
Agenda for Action, advised on the best use of people with long-term needs, but considerable
public funds to provide effective community work is still needed in Britain to ensure that
care. The White Paper Caring for People, pub- all patients have access to high-quality
lished in 1989, outlined the governments ideas community care when they need it. Problems
for developing these proposals further. The in providing such are are not confined to
plans were then enshrined in law with the the UK.
National Health Service and Community Care
Act of 1990. Community Health Services
Since April 1993, local social-services Usually managed by NHS trusts, these are a
departments have been responsible for assessing complex variety of services provided to people
what help people need from community-care outside hospital settings. The key parts are the
services: these can include home helps, meals services delivered by district nurses, health
on wheels, sheltered housing, etc. Recipients of visitors and therapists for example, physio-
such services are means-tested and make vari- therapists and speech therapists.
able contributions towards the costs. Policies on
charging vary from one area to another and Community Mental Health
there are wide geographical variations in the Teams
range of services provided free and the charges Intended as a key part of the NHSs local com-
levied for others. prehensive mental health services serving popu-
People with complex needs may be assigned a lations of around 50,000, these multi-
case manager to coordinate the care package disciplinary, multi-agency teams have been less
and ensure that appropriate responses are made effective than expected, in part due to varying
to changing circumstances. The success of modes of operation in different districts. Some
community care hinges on effective coordin- experts argue that the services they provide for
 154 Community Nurses

example, crisis intervention, liaison with pri- when this power becomes temporarily
mary care services and continuing care for insufficient.
long-term clients could be delivered more Compensation also refers to the financial
effectively by several specialist teams rather than compensation awarded to an individual who
a single, large generic one comprising psychi- has been injured or made ill as a result of
C atrists, psychologists, community mental health wrongful action or inaction by another indi-
nurses, occupational therapists, support and vidual or organisation. NHS trusts are increas-
(sometimes) social workers. ingly being sued for compensation because
patients believe that they have had unsatisfac-
Community Nurses tory or damaging treatment. This is costing the
A term that includes district nurses, health vis- NHS over 1 billion a year. (See RISK
itors, practice nurses and school nurses. While MANAGEMENT.)
customarily based in a general practice or a
health centre, they are independent health pro- Compensation neurosis Compensation
fessionals contracted to the NHS (see NURSING). neurosis or traumatic neurosis is a psycho-
logical reaction to the prospects of compensa-
Community Paediatrician tion. It is a condition about which specialists
Formerly entitled consultant paediatrician disagree. Sufferers complain of a range of symp-
(community child health), these are specialists toms that may be a genuine consequence of
dealing with children with chronic problems their condition or an exaggerated response.
not involving acute or hospital care. For
example, they have a primary role in dealing Complement
with disabled children, children with special Complement is a normal constituent of blood
educational needs and abused children. serum which plays an important part in the
antibody-antigen reaction which is the basis of
Community Physician many immunity processes. (See IMMUNITY.)
A doctor who works in the specialty that
encompasses PREVENTIVE MEDICINE, EPIDEMI- Complementary and
OLOGY and PUBLIC HEALTH. Alternative Medicine (CAM)
This is the title used for a diverse group of
Compatibility health-related therapies and disciplines which
The extent to which a persons defence systems are not considered to be a part of mainstream
will accept invading foreign substances for medical care. Other terms sometimes used to
example, an injection of a drug, a blood transfu- describe them include natural medicine, non-
sion or an organ transplant. When incompati- conventional medicine and holistic medicine.
bility occurs there is usually a rapid antibody CAM embraces those therapies which may
attack on the invading antigen with a severe either be provided alongside conventional
local or system reaction in the individual receiv- medicine (complementary) or which may, in
ing the antigenic substance. (See IMMUNITY.) the view of their practitioners, act as a substi-
tute for it. Alternative disciplines purport to
Compensation provide diagnostic information as well as offer-
In medical parlance, a term applied to the ing therapy. However, there is a move now to
counterbalancing of some defect of structure or integrate CAM with orthodox medicine and
function by some other special bodily develop- this view is supported by the Foundation for
ment. The body possesses a remarkable power Integrated Medicine in the UK in its report, A
of adapting itself even to serious defects, so that way forward for the next five years? A discussion
disability due to these passes off after a time. paper (1997).
The term is most often applied to the ability The University of Exeter Centre for Com-
possessed by the heart to increase in size, and plementary Health Studies report, published
therefore in power, when the need for greater in 2000, estimated that there are probably
pumping action arises in consequence of a more than 60,000 practitioners of comple-
defective valve or some other abnormality in the mentary and alternative medicine in the UK.
circulation (see also HEART, DISEASES OF; CIRCU- In addition there are about 9,300 therapist
LATORY SYSTEM OF THE BLOOD). A heart in this members of organisations representing practi-
condition is, however, more liable to be tioners who have statutory qualifications,
prejudicially affected by strains and disease- including doctors, nurses (see NURSING), mid-
processes, and the term failure of compensa- wives, osteopaths and physiotherapists; chiro-
tion is applied to the symptoms that result practors became fully regulated by statute in
 Compression Syndrome 155

June 2001. There are likely to be many thou- membranes called lytic components which
sands more health staff with an active interest hasten the destruction of foreign cells. (See
or involvement in the practice of comple- IMMUNOLOGY.)
mentary medicine for example, the 10,000
members of the Royal College of Nursings Complex
Complementary Therapy Forum. It is possible
The term applied to a combination of various C
that up to 20,000 statutory health profes-
actions or symptoms. It is particularly applied
sionals regularly practise some form of com-
to a set of symptoms occurring together in
plementary medicine including half of all gen-
mental disease with such regularity as to receive
eral practices providing access to CAMs
a special name.
most commonly manipulation therapies. The
report from the Centre at Exeter University
estimates that up to 5 million patients con- Complexion
sulted a practitioner specialising in comple- See ACNE; SKIN, DISEASES OF;
mentary and alternative medicine in 1999. PHOTODERMATOSES.
Surveys of users of complementary and alter-
native practitioners show a relatively high satis- Compliance
faction rating and it is likely that many The extent to which a patient follows the advice
patients will go on to use such therapists over of a doctor or other health professional, espe-
an extended period. The Exeter Centre esti- cially in respect of drug or other treatments.
mates that, with the increments of the last two This is generally increased if the patient under-
years, up to 1520 million people, possibly 33 stands both the condition and the basis for the
per cent of the population of the country, have proposed treatment. Assessment of a patients
now sought such treatment. compliance should be a routine part of
The 1998 meeting of the British Medical treatment review.
Association (BMA) agreed to investigate the
scientific basis and efficacy of acupuncture and
the quality of training and standards of con- Compress
fidence in its practitioners. In the resulting Compress is the name given to a pad of linen or
report (July 2000) the BMA recommended flannel wrung out of water and bound to the
that guidelines on CAM use for general practi- body. It is generally wrung out of cold water,
tioners, complementary medicine practitioners and may be covered with a piece of waterproof
and patients were urgently needed, and that material. It is used to subdue pain or inflamma-
the Department of Health should select key tion. A hot compress is generally called a
CAM therapies, including acupuncture, for FOMENTATION.
appraisal by the National Institute for Clinical
Medicine (NICE). The BMA also reiterated its Compressed Air Illness
earlier recommendation that the main CAM Also known as caisson disease, this affects
therapies, including acupuncture, should be workers operating in compressed-air environ-
included in familiarisation courses on CAM ments, such as underwater divers and workers
provided within medical schools, and that in caissons (such as an ammunition wagon, a
accredited postgraduate education should be chest of explosive materials, or a strong case for
provided to inform GPs and other clinicians keeping out the water while the foundations of
about the possible benefits of CAM for a bridge are being built; derived from the
patients. French caisse, meaning case or chest). Its chief
symptoms are pains in the joints and limbs
Complement System (bends); pain in the stomach; headache and
This is part of the bodys defence mechanism dizziness; and paralysis. Sudden death may
that comprises a series of 20 serum peptides (see occur. The condition is caused by the accumu-
PEPTIDE). These are sequentially activated to
lation of bubbles of nitrogen in different parts
produce three significant effects: firstly, the of the body, usually because of too-rapid
release of small peptides which provoke decompression when the worker returns to
inflammation and attract phagocytes (see normal atmospheric presure a change that
PHAGOCYTE); secondly, the deposition of a
must be made gradually.
substance (component C3b) on the membranes
of invading bacteria or viruses, attracting
phagocytes to destroy the microbes; thirdly, the Compression Syndrome
activation of substances that damage cell See MUSCLES, DISORDERS OF.
 156 Computed Tomography

Computed Tomography Computerised Tomography

Tomography is an X-ray examination technique See COMPUTED TOMOGRAPHY.
in which only structures in a particular plane
produce clearly focused images. Whole-body Conception
computed tomography was introduced in 1977 Conception signifies the complex set of changes
C and has already made a major impact in the which occur in the OVUM and in the body of
investigation and management of medical and the mother at the beginning of pregnancy. The
surgical disease. The technique is particularly precise moment of conception is that at which
valuable where a mass distorts the contour of an the male element, or spermatozoon, and the
organ (e.g. a pancreatic tumour see PANCREAS, female element, or ovum, fuse together. Only
DISORDERS OF) or where a lesion has a density one-third of these conceptions survive to birth,
different from that of surrounding tissue (e.g. a whilst 15 per cent are cut short by spontaneous
metastasis in the LIVER). abortion or stillbirth. The remainder over
Computed tomography can distinguish soft one-half are lost very early during pregnancy
tissues from cysts or fat, but in general soft- without trace. (See also FETUS.)
tissue masses have similar appearances, so that
distinguishing an inflammatory mass from a Concussion of the Brain
malignant process may be impossible. The See BRAIN INJURIES.
technique is particularly useful in patients with
suspected malignancy; it can also define the Conditioned Reflex
extent of the cancer by detecting enlarged The development of a specific response by an
lymph nodes, indicating lymphatic spread. The individual to a specific stimulus. The best-
main indications for computed tomography of known conditioned reflex is the one described
the body are: mediastinal masses, suspected by Ivan Pavlov, in which dogs that became
pulmonary metastases, adrenal disease, pan- accustomed to being fed when a bell was
creatic masses, retroperitoneal lymph nodes, sounded salivated on hearing the bell, even if no
intra-abdominal abscesses, orbital tumours and food was given. The conditioned reflex is an
the staging of cancer as a guide to effective important part of behavioural theory.
treatment.
Condom
Computerised Decision-Support A thin rubber or plastic sheath placed over the
Systems erect PENIS before sexual intercourse. It is the
Also known as expert systems, these are com- most effective type of barrier contraception and
puter software systems intended to help doc- is also valuable in preventing the transfer
tors make clinical decisions. Primary care between sexual partners of pathogenic organ-
medicine is especially noted for its uncertainty isms such as gonococci, which cause GONOR-
by virtue of being most patients first point of RHOEA, and human immuno-deficiency virus,
contact with health care, confronting the clin- which may lead to AIDS (see AIDS/HIV). Sheaths
ician with many undifferentiated health prob- are most effective when properly used and with
lems. So far, these systems have not been as spermicides.
effective as expected because of a failure to ana- The female condom might be suitable for
lyse the needs of primary care. Simple pro- contraception when a woman misses a day or
cedures to prompt the delivery of treatment two of her contraceptive pill; if there is
to patients with chronic conditions have DYSPAREUNIA; when the perineum needs pro-
improved care quality, but work needs to be tection, for example, after childbirth; or in cases
done on their cost-effectiveness. The aim of of latex allergy to traditional condoms. Used
more complex computerised support systems properly with spermicide, it provides an effect-
will be to forecast likely future events and the ive barrier both to infections and to spermato-
possible effectiveness of proposed interven- zoa. Failure may result if the penis goes along-
tions, based on available information about the side the condom, if it gets pushed up into the
patient and an understanding of the risks and vagina, or if it falls out. (See CONTRACEPTION.)
efficacy of interventions by doctors and other
experts. Condyle
One example, called ISABEL, can be A rounded prominence at the end of a bone: for
accessed by paediatricians to check on their example, the prominences at the outer and
diagnosis and management of many childhood inner sides of the knee on the thigh-bone (or
disorders. FEMUR). The projecting part of a condyle is
sometimes known as an epicondyle, as in the
 Connective Tissue 157

case of the condyle at the lower end of possessed of separate personalities. Their fre-
the HUMERUS where the epicondyles form the quency is not known, but it has been estimated
prominences on the outer and inner side of the that throughout the world, six or more con-
elbow. joined twins are born every year who are cap-
able of separation. The earliest case on record is
Condyloma that of the Biddendon Maids who were born C
A localised, rounded swelling of mucous mem- in England in 1100. The Scottish Brothers
brane around the opening of the bowel, and the lived for 28 years at the court of James III of
genital organs, sometimes known as genital Scotland. Perhaps the most famous conjoined
warts or ano-genital warts. There are two twins, however, were Chang and Eng, who
main forms: condyloma latum, which is syphil- were born of Chinese parents in Siam in 1811.
itic in origin; and condyloma accuminatum, It was they who were responsible for the intro-
which often occurs in association with sexually duction of the term, Siamese twins, which still
transmitted disease, but is only indirectly due to remains the popular name for conjoined
it, being primarily a virus infection. twins. They were joined together at the lower
end of the chest bone, and achieved fame by
Cone being shown in Barnums circus in the United
(1) A light-sensitive cell in the retina of the EYE States. They subsequently married English sis-
that can also distinguish colours. The other ters and settled as farmers in North Carolina.
type of light-sensitive cell is called a rod. There They died in 1874.
are around six million cones in the human ret- The earliest attempt at surgical separation is
ina and these are thought to comprise three said to have been made by Dr Farius of Basle in
types that are sensitive to the three primary 1689. The first successful separation in Great
colours of red, blue, and green. Britain was in 1912: both twins survived the
(2) A cone biopsy is a surgical technique in operation and one survived well into adult life.
which a conical or cylindrical section of the This is said to be the first occasion on which
lower part of the neck of the womb is excised. both twins survived the operation. The success
of the operation is largely dependent upon the
Confidentiality degree of union between the twins. Thus, if this
The ethical principle that doctors do not reveal is only skin, subcutaneous tissue and cartilage,
information to other people (or to organisa- the prospects of survival for both twins are
tions) that their patients have given to them in good; but if some vital organ such as the liver is
confidence. Normally the doctor must get per- shared, the operation is much more hazardous.
mission to release confidential information to (See MULTIPLE BIRTHS.)
an employer (or other authoritative body),
insurance company or lawyer. The doctor does Conjugate Deviation
have to provide such information if required by The term for describing the persistent and
a court of law. (See ETHICS.) involuntary turning of both eyes in any one
direction, and is a sign of a lesion in the brain.
Congenital
Congenital deformities, diseases, etc. are those Conjunctiva
which are either present at birth, or which, See EYE.
being transmitted direct from the parents, show
themselves some time after birth. Conjunctivitis
See EYE, DISORDERS OF.
Congenital Adrenal Hyperplasia
See ADRENOGENITAL SYNDROME and GENETIC Connective Tissue
DISORDERS. Sometimes called fibrous tissue, this is one of
the most abundant tissues in the body, holding
Congestion together the bodys many different structures.
The accumulation of blood or other body fluid Connective tissue comprises a matrix of sub-
in a particular part of the body. The condition stances called mucopolysaccharides in which
may be due to some failure in the circulation, are embedded various specialist tissues and
but as a rule is one of the early signs of cells. These include elastic (yellow), collagenous
INFLAMMATION (see also ABSCESS; PNEUMONIA). (white) and reticular fibres as well as macro-
phages (see MACROPHAGE) and MAST CELLS.
Conjoined Twins Assembled in differing proportions, this pro-
Identical twins who are united bodily but are vides structures with varying functions: bone,
 158 Connective Tissue Disorders

cartilage, tendons, ligaments and fatty and elas- defined as fewer than three bowel openings a
tic tissues. Collagenous connective tissue binds week. Healthy people may have occasional
the muscles together and provides the substance bouts of constipation, usually reflecting a tem-
of skin. It is also laid down in wound repair, porary change in diet or the result of taking
forming the scar tissue. Contracting with time, drugs for example, CODEINE or any serious
C connective tissue becomes denser, causing the condition resulting in immobility, especially in
puckering that is typical in serious wounds or elderly people.
burns. (See ADHESION; SCAR; WOUNDS.) Constipation is a chronic condition and
must be distinguished from the potentially ser-
Connective Tissue Disorders ious disorder, acute obstruction, which may
A group of generalised inflammatory diseases have several causes (see under INTESTINE, DIS-
that affect CONNECTIVE TISSUE in almost any EASES OF). There are several possible causes of
system in the body. The term does not include constipation; those due to gastrointestinal dis-
those disorders of genetic origin. RHEUMATIC orders include:
FEVER and RHEUMATOID ARTHRITIS were trad- Dietary: lack of fibre; low fluid consump-
itionally classified in this group, as were those tion.
diseases classed under the outdated heading
COLLAGEN DISEASES.
Structural: benign strictures (narrowing of
gut); carcinoma of the COLON; DIVERTICU-
LAR DISEASE.
Consanguinous
A relationship by blood: siblings are closely
Motility: poor bowel training when young;
slow transit due to reduced muscle activity in
consanguinous; cousins, and grandparents and the colon, occurring usually in women;
grandchildren, less so. (See INBREEDING.) IRRITABLE BOWEL SYNDROME (IBS); HIRSCHS-
PRUNGS DISEASE.
Conscientious Objection Defaecation: anorectal disease such as fis-
See ETHICS. sures, HAEMORRHOIDS and CROHNS DIS-
EASE; impaction of faeces.
Consciousness Non-gastrointestinal disorders causing con-
The state of being aware of physical events stipation include:
or mental concepts. A conscious person is
awake and responsive to his or her sur-
Drugs: opiates (preparations of OPIUM), iron
supplements, ANTACIDS containing alu-
roundings. (See also COMA; UNCONSCIOUS; minium, ANTICHOLINERGIC drugs.
ANAESTHESIA.) Metabolic and endocrine: DIABETES MEL-
LITUS, pregnancy (see PREGNANCY AND
Conservative Treatment LABOUR), hypothyroidism (see under THYROID
Medical treatment which involves the min- GLAND, DISEASES OF).
imum of active interference by the prac- Neurological: cerebrovascular accidents
titioner. For example, a disc lesion in the back (STROKE), MULTIPLE SCLEROSIS (MS), PAR-
might be treated by bed rest in contrast to KINSONISM, lesions in the SPINAL CORD.
surgical intervention to remove the damaged Persistent constipation for which there is no
disc. obvious cause merits thorough investigation,
and people who experience a change in bowel
Consolidation habits for example, alternating constipation
A term applied to solidification of an organ, and diarrhoea should also seek expert
especially of a lung. The consolidation may be advice.
of a permanent nature due to formation of
fibrous tissue, or may be temporary, as in acute Treatment Most people with constipation
pneumonia. will respond to a dietary supplement of fibre,
coupled, when appropriate, with an increase in
Constipation fluid intake. If this fails to work, judicious use
A condition in which a person infrequently of LAXATIVES for, say, a month is justified.
passes hard FAECES (stools). Patients sometimes Should constipation persist, investigations on
complain of straining, a feeling of incomplete the advice of a general practitioner will prob-
evacuation of faeces, and abdominal or perianal ably be needed; any further treatment will
discomfort. A healthy individual usually opens depend on the outcome of the investigations in
his or her bowels once daily but the frequency which a specialist will usually be involved. Suc-
may vary, perhaps twice daily or once only every cessful treatment of the cause should then
two or three days. Constipation is generally return the patients bowel habits to normal.
 Continuity of Care 159

Constitution tact lenses instead of glasses. Therapeutic lenses

Constitution, or DIATHESIS, means the general are those used in the treatment of eye disease:
condition of the body, especially with reference bandage lenses are used in certain corneal dis-
to its liability to certain diseases. eases; contact lenses can be soaked in a particu-
lar drug and then put on the eye so that the
Consultant drug slowly leaks out on to the eye. Contact C
In Britains health service a consultant is the lenses may be hard, soft or gas permeable.
senior career post for a fully accredited special- Hard lenses are more optically accurate
ist. He or she normally sees patients referred by (because they are rigid), cheaper and more
general practitioners hence the historical term durable than soft. The main advantage of soft
consultant or emergency cases admitted dir- lenses is that they are more comfortable to
ect to hospital. NHS consultants are also wear. Gas-permeable lenses are so-called
allowed to do a certain amount of private prac- because they are more permeable to oxygen
tice if they wish. After qualification and a two- than other lenses, thus allowing more oxygen
year period of general supervised training, doc- to reach the cornea.
tors enter onto a specialist training scheme, Disposable lenses are soft lenses designed to
working in hospitals for 58 years before being be thrown away after a short period of continu-
accredited; many also do research or spend ous use; their popularity rests on the fact that
some time working abroad. All must pass dif- they need not be cleaned. The instructions on
ficult higher examinations. In 2004, the num- use should be followed carefully because the
ber of consultant hospital medical and dental risk of complications, such as corneal infection,
staff in Great Britain was 30,650 (some of these are higher than with other types of contact
worked part-time, so the whole-time equivalent lenses.
[w.t.e.] figure was 25,640). The total number of Contraindications to the use of contact
hospital medical and dental staff was 86,996 lenses include a history of ATOPY, dry eyes,
(w.t.e. 78,462). previous GLAUCOMA surgery and a persons
inability to cope with the management of
Consumption lenses. The best way to determine whether
See TUBERCULOSIS. contact lenses are suitable, however, may be to
try them out. Good hygiene is essential for
Contact a Family wearers so as to minimise the risk of infec-
A charity which helps families with disabled tion, which may lead to a corneal abscess a
children to obtain good-quality information, serious complication. Corneal abrasions are
support and most of all contact with other fairly common and, if a contact-lens wearer
families with children who have the same dis- develops a red eye, the lens should be
order. This includes children with specific and removed and the eye tested with fluorescein
rare conditions and those with special edu- dye to identify any abrasions. Appropriate
cational needs. The charity has many local par- treatment should be given and the lens not
ent groups throughout the UK and publishes a worn again until the abrasion or infection has
comprehensive directory with brief descriptions cleared up.
of each condition followed by contact
addresses, phone numbers and web addresses. It Contagion
also has a central helpline and a team of parent Contagion means the principle of spread of dis-
advisers. ease by direct contact with the body of an
See www.cafamily.org.uk affected person.

Contact Lenses Continued Fevers

Contact lenses are lenses worn in contact with Continued fevers-are typhus, typhoid and
the EYE, behind the eyelids and in front of the relapsing fevers, so-called because of their con-
cornea. They may be worn for cosmetic, tinuing over a more or less definite space of
optical or therapeutic reasons. The commonest time.
reason for wear is cosmetic, many short-sighted
people preferring to wear contact lenses instead Continuity of Care
of glasses. Optical reasons for contact-lens wear A term describing a system of medical care in
include cataract surgery (usually unilateral which individuals requiring advice on their
extraction) and the considerable improvement health consult a named primary care physician
in overall standard of vision experienced by (GENERAL PRACTITIONER (GP)) or partnership of
very short-sighted people when wearing con- practitioners. The availability of an individuals
 160 Continuous Autologous Transfusion

medical records, and the doctors knowledge of sheath is the best protection against HIV infec-
his or her medical, family and social history, tion (see AIDS/HIV) for sexually active people.
should facilitate prompt, appropriate decisions The efficiency of barrier methods is improved if
about investigations, treatment or referral to they are used in conjunction with a spermicidal
specialists. What the doctor(s) know(s) about foam or jelly, but care is needed to ensure that
C the patient can, for example, save time, alert the preparation chosen does not damage the
hospitals to allergies, avoid the duplication of rubber barrier or cause an allergic reaction in
investigations and provide hospitals with prac- the users.
tical domestic information when a patient is CONDOM OR SHEATH This is the most com-
ready for discharge. The traditional 24-hours-a- monly used barrier contraceptive. It consists of
day, 365-days-a-year care by a personal phys- a rubber sheath which is placed over the erect
ician is now a rarity: continuity of care has penis before intromission and removed after
evolved and is now commonly based on a ejaculation. The failure rate, if properly used, is
multi-disciplinary health team working from about 4 per cent.
common premises. Changing social structures, DIAPHRAGM OR CAP A rubber dome that is
population mobility and the complexity and inserted into the vagina before intercourse and
cost of health care have driven this evolution. fits snugly over the cervix. It should be used
Some experts have argued that the changes are with an appropriate spermicide and is
so great as to make continuity of care an removed six hours after intercourse. A woman
unrealistic concept in the 21st century. Never- must be measured to ensure that she is sup-
theless, support inside and outside conventional plied with the correct size of diaphragm, and
medical practice for HOLISTIC medicine a the fit should be checked annually or after
related concept for treating the whole person, more than about 7 lbs. change in weight. The
body and mind and the fact that many people failure rate, if properly used, is about 2 per
still appreciate the facility to see their own doc- cent.
tors suggest that continuity of care is still a valid
objective of value to the community. Non-barrier methods These do not pro-
vide a physical barrier between sperm and cer-
Continuous Autologous vix and so do not protect against sexually
transmitted diseases, including HIV.
Transfusion COITUS INTERRUPTUS This involves the mans
See TRANSFUSION. withdrawing his penis from the vagina before
ejaculation. Because some sperm may leak
Continuous Positive Airways before full ejaculation, the method is not very
Pressure reliable.
A method for treating babies who suffer from SAFE PERIOD This involves avoiding intercourse
alveolar collapse in the lung as a result of HYA- around the time when the woman ovulates and
LINE MEMBRANE DISEASE (see also RESPIRATORY is at risk of pregnancy. The safe times can be
DISTRESS SYNDROME). predicted using temperature charts to identify
the rise in temperature before ovulation, or by
careful assessment of the quality of the cervical
Contraception mucus. This method works best if the woman
A means of avoiding pregnancy despite sexual has regular menstrual cycles. If used carefully
activity. There is no ideal contraceptive, and the it can be very effective but requires a highly
choice of method depends on balancing con- disciplined couple to succeed. It is approved by
siderations of safety, effectiveness and accept- the Catholic church.
ability. The best choice for any couple will SPERMICIDAL GELS, CREAMS, PESSARIES, ETC.
depend on their ages and personal circum- These are supposed to prevent pregnancy by
stances and may well vary with time. Contra- killing sperm before they reach the cervix, but
ceptive techniques can be classified in various they are unreliable and should be used only in
ways, but one of the most useful is into barrier conjunction with a barrier method.
and non-barrier methods. INTRAUTERINE CONTRACEPTIVE DEVICE
(COIL) This is a small metal or plastic shape,
Barrier methods These involve a physical placed inside the uterus, which prevents preg-
barrier which prevents sperm (see SPERMATO- nancy by disrupting implantation. Some
ZOON) from reaching the cervix (see CERVIX people regard it as a form of abortion, so it is
UTERI). Barrier methods reduce the risk of not acceptable to all religious groups. There is
spreading sexually transmitted diseases, and the a risk of pelvic infection and eventual infertil-
 Contre-Coup 161

ity in women who have used coils, and in many HORMONAL CONTRACEPTION FOR MEN There
countries their use has declined substantially. is a growing demand by men worldwide for
Coils must be inserted by a specially trained hormonal contraception. Development of a
health worker, but once in place they permit male pill, however, has been slow because of
intercourse at any time with no prior planning. the potentially dangerous side-effects of using
Increased pain and bleeding may be caused dur- high doses of TESTOSTERONE (the male hor- C
ing menstruation. If severe, such symptoms may mone) to suppress spermatogenesis. Progress in
indicate that the coil is incorrectly sited, and research to develop a suitable ANDROGEN-based
that its position should be checked. combination product is promising, including
HORMONAL METHODS Steroid hormones have the possibility of long-term STEROID implants.
dominated contraceptive developments during STERILISATION See also STERILISATION Repro-
the past 40 years, with more than 200 million ductive sterilisation. The operation is easier and
women worldwide taking or having taken the safer to perform on men than on women.
pill. In the past 20 years, new developments Although sterilisation can sometimes be
have included modifying existing methods reversed, this cannot be guaranteed and couples
and devising more effective ways of delivering should be counselled in advance that the
the drugs, such as implants and hormone- method is irreversible. There is a small but def-
releasing devices in the uterus. Established inite failure rate with sterilisation, and this
hormonal contraception includes the com- should also be made clear before the operation
bined oestrogen and progesterone and is performed.
progesterone-only contraceptive pills, as well POSTCOITAL CONTRACEPTION Also known as
as longer-acting depot preparations. They emergency contraception or the morning after
modify the womans hormonal environment pill, postcoital contraception can be effected
and prevent pregnancy by disrupting various by two different hormonal methods. Lev-
stages of the menstrual cycle, especially ovula- onorgesterol (a synthetic hormone similar to
tion. The combined oestrogen and progester- the natural female sex hormone PROGESTER-
one pills are very effective and are the most ONE) can be used alone, with one pill being
popular form of contraception. Biphasic and taken within 72 hours of unprotected inter-
triphasic pills contain different quantities of course, but preferably as soon as possible, and a
oestrogen and progesterone taken in two or second one 12 hours after the first. Alter-
three phases of the menstrual cycle. A wide natively, a combined preparation comprising
range of preparations is available and the Brit- ETHINYLESTRADIOL and levonorgesterol can be
ish National Formulary contains details of the taken, also within 72 hours of unprotected
commonly used varieties. intercourse. The single constituent pill has
The main side-effect is an increased risk of fewer side-effects than the combined version.
cardiovascular disease. The lowest possible dose Neither version should be taken by women
of oestrogen should be used, and many prepar- with severe liver disease or acute PORPHYRIAS,
ations are phasic, with the dose of oestrogen but the ethinylestradiol/levonorgesterol com-
varying with the time of the cycle. The bination is unsuitable for women with a his-
progesterone-only, or mini, pill does not con- tory of THROMBOSIS.
tain any oestrogen and must be taken at the In the UK the law allows women over the age
same time every day. It is not as effective as the of 16 to buy the morning-after pill over the
combined pill, but failure rates of less than counter from a registered pharmacist.
1-per-100 woman years can be achieved. It has
few serious side-effects, but may cause men- Contracture
strual irregularities. It is suitable for use by The permanent shortening of a muscle or of
mothers who are breast feeding. fibrous tissue. Contraction is the name given to
Depot preparations include intramuscular the temporary shortening of a muscle.
injections, subcutaneous implants, and intrav-
aginal rings. They are useful in cases where the Contrast Medium
woman cannot be relied on to take a pill regu- A material that is used to increase the visibility
larly but needs effective contraception. Their of the bodys tissues and organs during RADI-
main side-effect is their prolonged action, OGRAPHY. A common example is the use of bar-
which means that users cannot suddenly decide ium which is given by mouth or as an enema to
that they would like to become pregnant. Skin show up the alimentary tract.
patches containing a contraceptive that is
absorbed through the skin have recently been Contre-Coup
launched. An injury in which a bone, generally the skull,
 162 Controlled Drugs

is fractured not at the spot where the violence In 1997 the Misuse of Drugs (Supply to
is applied, but at the exactly opposite point. Addicts) Regulations 1997 revoked the 1973
requirement for notification. Doctors are now
Controlled Drugs expected to report (on a standard form) cases of
In the United Kingdom, controlled drugs are drug misuse to their local Drug Misuse Data-
C those preparations referred to under the Misuse base (DMD). Notification by the doctor
of Drugs Act 1971. The Act prohibits activities should be made when a patient first presents
related to the manufacture, supply and posses- with a drug problem or when he or she visits
sion of these drugs, and they are classified into again after a gap of six months or more. All
three groups which determine the penalties for types of misuse should be reported: this
offences involving their misuse. For example, includes opioids, benzodiazepines and central
class A includes COCAINE, DIAMORPHINE, nervous system stimulants. The data in the
MORPHINE, LSD (see LYSERGIC ACID DIETHYL- DMD are anonymised, which means that
AMIDE and PETHIDINE HYDROCHLORIDE. Class doctors cannot check on possible multiple
B includes AMPHETAMINES, BARBITURATES and prescribing for drug addicts.
CODEINE. Class C includes drugs related to The 1997 Regulations restrict the prescrib-
amphetamines such as diethylpropion and ing of diamorphine (heroin), Diconal (a
chlorphentermine, meprobamate and most morphine-based drug) or cocaine to medical
BENZODIAZEPINES and CANNABIS. practitioners holding a special licence issued by
The Misuse of Drugs Regulations 1985 the Home Secretary.
define the classes of person authorised to supply Fuller details about the prescription of
and possess controlled drugs, and lay down the controlled drugs are in the British National
conditions under which these activities may be Formulary, updated twice a year, and available
carried out. In the Regulations, drugs are div- on the Internet (see www.bnf.org).
ided into five schedules specifying the require-
ments for supply, possession, prescribing and Contusion
record-keeping. Schedule I contains drugs See BRUISES.
which are not used as medicines. Schedules II
and III contain drugs which are subject to the Convalescence
prescription requirements of the Act (see below). The condition through which a person passes
They are distinguished in the British National after having suffered from some acute disease,
Formulary (BNF) by the symbol CD and they and before complete health and strength are
include morphine, diamorphine (heroin), other regained.
opioid analgesics, barbiturates, amphetamines,
cocaine and diethylpropion. Schedules IV and Convergence
V contain drugs such as the benzodiazepines (1) Inward turning of the eyes to focus on a
which are subject to minimal control. A full list near point, with the result that a single image is
of the drugs in each schedule can be found in registered by both retinas.
the BNF. (2) The coming together of various nerve fibres
Prescriptions for drugs in schedules II and III to form a nerve tract that provides a single
must be signed and dated by the prescriber, pathway from different parts of the brain.
who must give his or her address. The prescrip-
tion must be in the prescribers own handwrit- Conversion Disorder
ing and provide the name and address of the A psychological disorder, also called hysterical
patient and the total quantity of the preparation conversion, in which the affected individual
in both words and figures. The pharmacist is presents with striking neurological symptoms
not allowed to dispense a controlled drug unless such as weakness, paralysis, sensory disturb-
all the information required by law is given on ances or memory loss for which no organic
the prescription. cause can be identified. Up to 4 per cent of
Until 1997 the Misuse of Drugs (Notifica- patients attending neurological outpatient
tion and Supply of Addicts) Regulations 1973 clinics have been estimated as having con-
governed the notification of addicts. This was version disorders. The disorder remains
required in respect of the following commonly controversial, with theories about its cause
used drugs: cocaine, dextromoramide, diamor- unsupported by controlled research results. In
phine, dipipanone, hydrocodeine, hydromor- clinical practice the physicians experience and
phone, levorphanol, methadone, morphine, intuition are major factors in diagnosis. It has
opium, oxycodone, pethidine, phenazocine and been suggested that the physical symptoms rep-
piritranide. resent guilt about a physical or emotional
 Cordotomy 163

assault on someone else. Treatment using a cells; the other, indirect, method identifies
COGNITIVE BEHAVIOUR approach may help those circulating unattached in the serum.
those with conversion disorders.
Coordination
Convolutions The governing power exercised by the brain as a
See BRAIN. whole, or by certain centres in the nervous sys- C
tem, to make various muscles contract in har-
Convulsions mony and so produce definite actions (instead
Rapidly alternating contractions and relaxa- of meaningless movements). Coordination is
tions of the muscles, causing irregular move- intimately bound up with the complex sense of
ments of the limbs or body generally, usually localisation, which enables a person with their
accompanied by unconsciousness. eyes shut to tell, by sensations received from the
bones, joints and muscles, the position of the
Causes The most common reason for convul- various parts of their body.
sions is EPILEPSY, and the underlying cause of The power is impaired in various diseases,
the latter often remains uncertain. In newborns, such as LOCOMOTOR ATAXIA. It is tested by
convulsions may be due to HYPOXIA following a making the patient shut their eyes, moving their
difficult labour, or to low levels of sugar or cal- hand in various directions, and then telling
cium in the blood (HYPOGLYCAEMIA; HYPO- them to bring the point of the forefinger stead-
CALCAEMIA). A sudden rise of body tempera- ily to the tip of the nose or by other simple
ture during infective illness may induce convul- movements.
sions in an infant or young child.
Diseases of the brain, such as meningitis, Copper
encephalitis and tumours, or any disturbance Copper is an essential nutrient for humans, and
of the brain due to bleeding, blockage of a all tissues in the human body contain traces of
blood vessel, or irritation of the brain by a frac- it. The total amount in the adult body is 100
ture of the skull, may also be responsible for 150 mg. Many essential enzyme systems are
convulsions (see BRAIN, DISEASES OF). dependent on traces of copper; on the other
Asphyxia, for example from choking, may hand, there is no evidence that dietary
also bring on convulsions. deficiency of copper ever occurs in humans.
Infants are born with an ample store, and the
Treatment Newborns with hypoglycaemia or normal diet for an adult contains around 2 mg
hypocalcaemia are treated by replacing the miss- of copper a day. It is used in medicine as the two
ing compound. Infants with febrile convulsions salts, sulphate of copper (blue stone) and nitrate
may be sponged with tepid water and fever of copper. The former is, in small doses, a
reduced with paracetamol. powerful astringent, and in larger doses an irri-
In epilepsy, unless it is particularly severe, the tant. Both are caustics when applied externally.
movements seldom need to be restrained. If con- Externally, either is used to rub on unhealthy
vulsions persist beyond a few minutes it may be ulcers and growths to stimulate the granulation
necessary to give BENZODIAZEPINES, either tissue to more rapid healing.
intravenously or rectally. In the UK, paramedics
are trained to do this; likewise many parents of
epileptic children are capable of administering Coprolalia
the necessary treatment. If however this fails to An inherited condition, usually beginning in
stop the convulsions immediately, hospital childhood. It presents with motor tics and with
admission is needed for further treatment. irrepressible, explosive, occasionally obscene,
Once fits are under control, the cause of the verbal ejaculations. (See GILLES DE LA
TOURETTES SYNDROME.)
convulsions must be sought and the necessary
long-term treatment given.
Copulation
Cooleys Anaemia The act of coitus or sexual intercourse, when
See THALASSAEMIA. the man inserts his erect penis into the womans
vagina and after a succession of thrusting
Coombs Test movements ejaculates his semen.
A sensitive test that detects ANTIBODIES to the
bodys red cells (see ERYTHROCYTE). There are Cordotomy
two methods: one the direct method iden- The surgical operation of cutting the antero-
tifies those antibodies that are bound to the lateral tracts of the SPINAL CORD to relieve
 164 Cornea

otherwise intractable pain. It is also sometimes OPODY). Bunions may require surgical treat-
known as tractotomy. ment. Regular foot care is important in patients
with DIABETES MELLITUS.
Cornea
See EYE. Coronary
C A term applied to several structures in the body
Corneal Graft encircling an organ in the manner of a crown.
Also known as keratoplasty. If the cornea (see The coronary arteries are the arteries of supply
EYE) becomes damaged or diseased and vision is to the HEART which arise from the aorta, just
impaired, it can be removed and replaced by a beyond the aortic valve, and through which the
corneal graft. The graft is taken from the cornea blood is delivered to the muscle of the heart.
of a human donor. Some of the indications for Disease of the coronary arteries is a very serious
corneal grafting include keratoconus (conical- condition producing various abnormal forms
shaped cornea), corneal dystrophies, severe cor- of heart action and the disorder, ANGINA
neal scarring following HERPES SIMPLEX, and PECTORIS.
alkali burns or other injury. Because the graft is
a foreign protein, there is a danger that the Coronary Angioplasty
recipients immune system may set up a reac- A technique of dilating atheromatous obstruc-
tion causing rejection of the graft. Rejection tions (see ATHEROMA) in CORONARY ARTERIES
results in OEDEMA of the graft with subsequent by inserting a catheter with a balloon on the
poor vision. Once a corneal graft has been taken end into the affected artery (see also CATHETERS).
from a donor, it should be used as quickly as It is passed through the blockage (guided by X-
possible. Corneas can be stored for days in ray FLUOROSCOPY) and inflated. The procedure
tissue-culture medium at low temperature. A can be carried out through a percutaneous
small number of grafts are autografts in which a route.
patients cornea is repositioned.
The Department of Health has drawn up a Coronary Arteries
list of suitable eye-banks to which people can (See also HEART.) The right coronary artery arises
apply to bequeath their eyes, and an official from the right aortic sinus and passes into the
form is now available for the bequest of eyes. right atrio-ventricular groove to supply the
(See also DONORS; TRANSPLANTATION.) right ventricle, part of the intraventricular sep-
tum and the inferior part of the left ventricle.
Corneal Reflex The left coronary artery arises from the left
Instinctive closing of the eyelids when the sur- sinus and divides into an anterior descending
face of the cornea (see EYE) is lightly touched branch which supplies the septum and the
with a fine hair. anterior and apical parts of the heart, and the
circumflex branch which passes into the left
Corns and Bunions atrio-ventricular groove and supplies the lateral
A corn is a localised thickening of the cuticle or posterior surfaces of the heart. Small anasto-
epidermis (see SKIN) affecting the foot. The moses exist between the coronary arteries and
thickening is of a conical shape; the point of the they have the potential of enlarging if the
cone is directed inwards and is known as the blood-flow through a neighbouring coronary
eye of the corn. A general thickening over a artery is compromised. Coronary artery disease
wider area is called a callosity. Bunion is a con- is damage to the heart caused by the narrowing
dition found over the joint at the base of the big or blockage of these arteries. It commonly
toe, in which not only is there thickening of the presents as ANGINA PECTORIS or acute
skin, but the head of the metatarsal bone also myocardial infarction (see HEART, DISEASES OF).
becomes prominent. Hammer-toe is a condi-
tion of the second toe, often caused by short Coronary Artery Vein Bypass
boots, in which the toe becomes bent at its two Grafting (CAVBG)
joints in such a way as to resemble a hammer. When coronary arteries, narrowed by disease,
Corns and bunions are caused by badly fit- cannot supply the heart muscle with sufficient
ting shoes, hence the importance of children blood, the cardiac circulation may be improved
and adults wearing properly fitted footwear. by grafting a section of vein from the leg to
Corns can be pared after softening in warm bypass the obstruction. Around 10,000 people
water, or painted with salicylic acid collodion or in the United Kingdom have this operation
other proprietary preparations. Bad corns may annually and the results are usually good. It is a
need treatment by a chiropodist (see CHIR- major procedure that lasts several hours and
 Corticosteroids 165

requires the heart to be stopped temporarily, material. The follicle and its luteal cells consti-
with blood circulation and oxygenation taken tute the corpus luteum. The corpus luteum
over by a HEART-LUNG MACHINE. begins to disappear after ten days, unless the
discharged ovum is fertilised and pregnancy
Coronary Care Unit (CCU) ensues. In pregnancy the corpus luteum persists
A specialised hospital unit equipped and staffed and grows and secretes the hormone, C
to provide intensive care (see INTENSIVE THER- PROGESTERONE.
APY UNIT (ITU)) for patients who have had
severe heart attacks or undergone surgery on Corrigans Pulse
the heart. The name applied to the collapsing pulse found
with incompetence of the hearts aortic valve. It
Coronary Thrombosis is so-called after Sir Dominic John Corrigan
See HEART, DISEASES OF. (180280), the famous Dublin physician, who
first described it.
Coronaviruses
Coronaviruses so-called because in electron Corrosives
micrographs the spikes projecting from the Corrosives are poisonous substances which cor-
virus resemble a crown are a group of viruses rode or eat away the skin or the mucous sur-
which have been isolated from people with faces of mouth, gullet and stomach with which
common colds (see COLD, COMMON) and have they come into contact. Examples are strong
also been shown to produce common colds mineral acids like sulphuric, nitric and hydro-
under experimental conditions. Their precise chloric acids, caustic alkalis, and some salts like
significance in the causation of the common chlorides of mercury and zinc. (See POISONS.)
cold is still undetermined.
Corset
Coroner A support device worn around the trunk to help
An independent legal officer of the Crown who in the treatment of backache and spinal injuries
is responsible for deciding whether to hold a or disorders.
POST-MORTEM EXAMINATION and an inquest in
cases of sudden or unexpected or unnatural Cortex
death. He or she presides over an inquest, if The tissues that form the outer part of an organ
held sometimes with the help of a jury. Cor- and which are positioned just below the capsule
oners are usually lawyers or doctors (some are or outer membrane. Examples are the cerebal
double-qualified) who have been qualified for at cortex of the BRAIN and the renal cortex of the
least five years. In Scotland the coroner is KIDNEYS.
known as the procurator fiscal.
Corticosteroids
Corpulence The generic term for the group of hormones
See OBESITY. produced by the ADRENAL GLANDS, with a pro-
found effect on mineral and glucose
Cor Pulmonale metabolism.
Another name for pulmonary heart disease, Many modifications have been devised of the
which is characterised by hypertrophy and fail- basic steroid molecule in an attempt to keep
ure of the right VENTRICLE of the heart as a useful therapeutic effects and minimise
result of disease of the LUNGS or disorder of the unwanted side-effects. The main corticosteroid
pulmonary circulation. hormones currently available are CORTISONE,
HYDROCORTISONE, PREDNISONE, PRED-
Corpuscle NISOLONE, methyl prednisolone, triamci-
Corpuscle means a small body. (See BLOOD.) nolone, dexamethasone, betamethasone,
paramethasone and deflazacort.
Corpus Luteum They are used clinically in three quite dis-
The mass of cells formed in the ruptured Graa- tinct circumstances. First they constitute
fian follicle in the ovary (see OVARIES) from replacement therapy where a patient is unable
which the ovum is discharged about 15 days to produce their own steroids for example, in
before the onset of the next menstrual period adrenocortical insufficiency or hypopituitarism.
(see MENSTRUATION). When the ovum escapes, In this situation the dose is physiological
the follicle fills up with blood; this is soon namely, the equivalent of the normal adrenal
replaced by cells which contain a yellow fatty output under similar circumstances and is not
 166 Corticotropin

associated with any side-effects. Secondly, ster- prednisolone, or more, will cause hyper-
oids are used to depress activity of the adrenal cortisonism; less than 10 mg prednisolone a
cortex in conditions where this is abnormally day may be tolerated by most patients indefin-
high or where the adrenal cortex is producing itely. Inhaled steroids rarely produce any ill-
abnormal hormones, as occurs in some hirsute effect apart from a propensity to oral thrush
C women. (CANDIDA infection) unless given in excessive
The third application for corticosteroids is in doses.
suppressing the manifestations of disease in a General side-effects may include weight gain,
wide variety of inflammatory and allergic con- fat distribution of the cushingoid type, ACNE
ditions, and in reducing antibody production and HIRSUTISM, AMENORRHOEA, striae and
in a number of AUTOIMMUNE DISORDERS. The increased bruising tendency. The more serious
inflammatory reaction is normally part of the complications which can occur during long-
bodys defence mechanism and is to be encour- term treatment include HYPERTENSION,
aged rather than inhibited. However, in the case oedema, DIABETES MELLITUS, psychosis, infec-
of those diseases in which the bodys reaction is tion, DYSPEPSIA and peptic ulceration, gastro-
disproportionate to the offending agent, such intestinal haemorrhage, adrenal suppression,
that it causes unpleasant symptoms or frank ill- osteoporosis (see BONE, DISORDERS OF), myopa-
ness, the steroid hormones can inhibit this thy (see MUSCLES, DISORDERS OF), sodium
undesirable response. Although the underlying retention and potassium depletion.
condition is not cured as a result, it may resolve
spontaneously. When corticosteroids are used Corticotropin
for their anti-inflammatory properties, the dose Corticotropin is the British Pharmacopoeia
is pharmacological; that is, higher often much name for the adrenocorticotrophic hormone of
higher than the normal physiological the PITUITARY GLAND, also known as ACTH. It
requirement. Indeed, the necessary dose may is so-called because it stimulates the functions
exceed the normal maximum output of the of the cortex of the suprarenal glands. This
healthy adrenal gland, which is about 250300 results, among other things, in an increased
mg cortisol per day. When doses of this order output of cortisone.
are used there are inevitable risks and side-
effects: a drug-induced CUSHINGS SYNDROME Cortisol
will result. Another name for HYDROCORTISONE.
Corticosteroid treatment of short duration,
as in angioneurotic OEDEMA of the larynx or Cortisone
other allergic crises, may at the same time be An early corticosteroid drug (see CORTICO-
life-saving and without significant risk (see STEROIDS), now obsolete and replaced by
URTICARIA). Prolonged therapy of such PREDNISOLONE and HYDROCORTISONE.
connective-tissue disorders, such as POLYAR-
TERITIS NODOSA with its attendant hazards, is Corynebacteria
generally accepted because there are no other A genus of aerobic and anaerobic gram-positive
agents of therapeutic value. Similarly the (see GRAMS STAIN) bacteria, widely distributed
absence of alternative medical treatment for and best known as parasites and pathogens in
such conditions as autoimmune haemolytic humans. C. diphtheria, a prime example, causes
ANAEMIA establishes steroid therapy as the diphtheria.
treatment of choice which few would dispute.
The use of steroids in such chronic conditions Coryza
as RHEUMATOID ARTHRITIS, ASTHMA and Coryza is the technical name for a cold in the
DERMATITIS needs careful assessment and head (see COLD, COMMON).
monitoring.
Although there is a risk of ill-effects, these Costal
should be set against the misery and danger of Anything pertaining to the ribs.
unrelieved chronic asthma or the incapacity,
frustration and psychological trauma of Costalgia
rheumatoid arthritis. Patients should carry Pain in the ribs.
cards giving details of their dosage and possible
complications. Cost of Illness
The incidence and severity of side-effects are Traditionally, doctors have been trained to treat
related to the dose and duration of treatment. a patient on the basis of his or her personal
Prolonged daily treatment with 15 mg of clinical needs. Increasingly, however, the prac-
 Cough 167

tice of medicine has been influenced by PASSAGES and LUNGS. Air is drawn into the air
patients social circumstances and more recently passages with the GLOTTIS wide open. The
by community- and government-driven inhaled air is blown out against the closed glot-
national priorities. One critical aspect of these tis, which, as the pressure builds up, suddenly
widening influences has been the cost of med- opens, expelling the air at an estimated speed
ical care which, as medicine becomes more of 960 kilometres (600 miles) an hour. This C
complex, has been rising sharply. Thus health explosive exhalation expels harmful substances
economics has become an integral part of the from the respiratory tract. Causes of coughing
provision of health care. Cost-of-illness studies include infection for example, BRONCHITIS or
now appear commonly in medical publications. PNEUMONIA; inflammation of the respiratory
Such studies aim to identify and measure all the tract associated with ASTHMA; and exposure to
costs of a particular disease, including, where irritant agents such as chemical fumes or smoke
feasible, the direct, indirect and intangible (see also CROUP).
dimensions. The information obtained is The explosive nature of coughing results in a
intended to help the development of health spray of droplets into the surrounding air and,
policies, nationally and internationally. The if these are infective, hastens the spread of colds
application of information from such studies (see COLD, COMMON) and INFLUENZA. Cough-
is, however, proving controversial. Firstly, doc- ing is, however, a useful reaction, helping the
tors still see their clinical responsibilities to body to rid itself of excess phlegm (mucus) and
patients as a priority. Secondly, cost-of-care other irritants. The physical effort of persistent
studies are often criticised for excluding coughing, however, can itself increase irritation
broader economic aspects of health care for of the air passages and cause distress to the
example, analyses of the cost-effectiveness of patient. Severe and protracted coughing may,
prevention as well as the treatment of illness. rarely, fracture a rib or cause PNEUMOTHORAX.
This requires assessment of potential and Coughs can be classified as productive when
actual outcomes as well as the costs of ill- phlegm is present and dry, when little or no
nesses. Even so, the increasing complexity of mucus is produced.
medicine, with its commensurately rising costs Most coughs are the result of common-cold
affecting both state- and privately funded infections but a persistent cough with yellow or
medical care, makes it inevitable that the cost green sputum is indicative of infection, usually
of maintaining a populations good health will bronchitis, and sufferers should seek medical
be a growing factor in the provision of health advice as medication and postural drainage (see
care that seems bound to impinge on how PHYSIOTHERAPY) may be needed. PLEURISY,
doctors are enabled to treat their individual pneumonia and lung CANCER are all likely to
patients. cause persistent coughing, sometimes associated
with chest pain, so it is clearly important for
Cot Death people with a persistent cough, usually accom-
See SUDDEN INFANT DEATH SYNDROME (SIDS). panied by malaise or PYREXIA, to seek medical
advice.
Co-Trimoxazole
This drug a mixture of trimethoprim and the Treatment Treatment of coughs requires
sulphonamide, sulphamethoxazole should be treatment of the underlying cause. In the case of
used only in the prophylaxis or treatment colds, symptomatic treatment with simple rem-
of pneumocystis PNEUMONIA, and in acute edies such as inhalation of steam is usually as
exacerbations of chronic BRONCHITIS, urinary effective as any medicines, though ANALGESICS
tract infections and otitis media (see EAR, or ANTIPYRETICS may be helpful if pain or a
DISEASES OF), where indicated. raised temperature are among the symptoms.
Many over-the-counter preparations are
Cotton Wool available and can help people cope with the
Cotton wool, or absorbent cotton as it is now symptoms. Preparations may contain an
technically named by the British Pharmaco- analgesic, antipyretic, decongestant or anti-
poeia, is a downy material made from the hairs histamine in varying combinations. Cough
on cotton plant seeds (Gossypium herbaceum). It medicines are generally regarded by doctors
is used in medicine in wound-dressing packs, as ineffective unless used in doses so large
skin-cleaning procedures, etc. they are likely to cause sedation as they act on
the part of the brain that controls the cough
Cough reflex.
A natural reflex reaction to irritation of the AIR Cough suppressants may contain CODEINE,
 168 Cough Syncope

DEXTROMETHORPHAN, PHOLCODINE and Counselling

sedating ANTIHISTAMINE DRUGS. Expectorant Psychological support and advice provided by a
preparations usually contain subemetic doses of trained therapist or health professional. The
substances such as ammonium chloride, IPE- aim is to help an individual manage a particular
CACUANHA, and SQUILL (none of which have personal or family problem: this may be a diag-
C proven worth), while demulcent preparations nosis of cancer, mental and physical trauma fol-
contain soothing, harmless agents such as syrup lowing an accident or assault, or a bereavement.
or glycerol. Counselling can help people cope with a wide
A list of systemic cough and decongestant range of demanding circumstances. It is usually
preparations on sale to the public, together with done on a one-to-one basis sometimes in
their key ingredients, appears in the British small groups and needs to be provided with
National Formulary. skill and sensitivity or there is a risk of worsen-
ing the individuals difficulties. There has been
Cough Syncope rapid growth in counselling services and it is
Temporary loss of consciousness that may be vital that those providing them have been prop-
induced by a severe spasm of coughing. This is erly trained.
the result of the high pressure that may be
induced in the chest over 200 millimetres of Cowpers Glands
mercury by such a spasm, which prevents the Also known as the bulbourethral glands, these
return of blood to the heart. The veins in the are a pair of glands whose ducts open into the
neck begin to bulge and the blood pressure falls; urethra at the base of the PENIS. They secrete a
this may so reduce the blood flow to the brain fluid that is one of the constituents of the
that the individual feels giddy and may then SEMEN which carries the spermatozoa and is
lose consciousness. (See FAINTING.) ejaculated into the VAGINA during coitus (sexual
intercourse).
Council for Healthcare
Regulatory Excellence Cowpox
In 2002 the UK government set up this new Cowpox is a disease affecting the udders of
statutory council with the aim of improving cows, on which it produces vesicles (see VESICLE;
consistency of action across the eight existing PAPULE). It is communicable to humans, and
regulatory bodies for professional staff involved there has for centuries been a tradition that per-
in the provision of various aspects of health sons who have caught this disease from cows do
care. These bodies are: General Medical Coun- not suffer afterwards from SMALLPOX. This
cil; General Dental Council; General Optical formed the basis for Jenners experiments on
Council; Royal Pharmaceutical Society of VACCINATION.
Great Britain; General Chiropractic Council;
General Osteopathic Council; Health Profes- COX-2 Inhibitors
sions Council; and Nursing and Midwifery This stands for cyclo-oxygenase 2 inhibitors a
Council. class of drugs used in treating ARTHRITIS of
The new Council for Healthcare Regulatory which the most well-used is celecoxib. Their
Excellence will help to promote the interests of main claim is that they are less likely to cause
patients and to improve co-operation between gastrointestinal disturbance than NON-
the existing regulatory bodies providing, STEROIDAL ANTI-INFLAMMATORY DRUGS
in effect, a quality-control mechanism for (NSAIDS). In 2001, the National Institute for
their activities. The government and relevant Clinical Excellence (NICE) recommended
professions will nominate individuals for that they should not be used routinely in
this overarching council. The new council rheumatoid arthritis or osteoarthritis but only
will not have the authority to intervene in in patients with a history of peptic ulcer or
the determination by the eight regulatory gastrointestinal bleeding. They should also be
bodies of individual fitness-to-practise cases considered in persons over the age of 65 tak-
unless these concern complaints about ing other drugs which could cause gastro-
maladministration. intestinal bleeding, those who are very debili-
tated, and those who are taking maximum
Council for Nursing and doses of NSAIDs. In 2005, rofecoxib was
Midwifery withdrawn because of concerns about cardiac
See APPENDIX 7: STATUTORY ORGANISATIONS. side-effects.
 Creatinine Clearance 169

Coxalgia usually responds to a daily shampoo with cet-

Pain in the hip-joint; also referred to as rimide solution. Warm olive oil gently mas-
coxodynia. saged into the scalp and left overnight, after
which the scales can be washed off, also helps
Coxa Vara with the condition.
A condition in which the neck of the thigh- C
bone is bent so that the lower limbs are turned Cramp
outwards and lameness results. See MUSCLES, DISORDERS OF.

Coxsackie Viruses Cranial Nerves

A group of viruses so-called because they were Cranial nerves are those arising from the BRAIN.
first isolated from two patients with a disease
resembling paralytic POLIOMYELITIS, in the vil- Craniotomy
lage of Coxsackie in New York State. Thirty The removal of part of the SKULL to provide
distinct types have now been identified. They surgical access for an operation on the BRAIN.
constitute one of the three groups of viruses This may be to obtain a BIOPSY, to remove a
included in the family of ENTEROVIRUSES, and tumour or to drain an infection or a blood clot.
are divided into two groups: A and B. Despite Following the operation the bone is replaced,
the large number of types of group A virus (24) along with the membranes, muscle and skin.
in existence, evidence of their role in causing
human disease is limited. Some, however, cause
Cranium
The part of the skull enclosing the brain as dis-
aseptic MENINGITIS, non-specicifc upper
tinguished from the face.
respiratory infection and MYOCARDITIS, and
others cause a condition known as HERPAN- Cream
GINA. HAND, FOOT AND MOUTH DISEASE is The oily or fatty part of milk from which butter
another disease caused by the A group. All six is prepared. Various medicinal preparations are
types of group B virus have been associated with known also as cream for example, cold cream,
outbreaks of aseptic meningitis, and they are which is a simple ointment containing rose-
also the cause of BORNHOLM DISEASE. Epidem- water, beeswax, borax, and almond oil scented
ics of type B2 infections tend to occur in alter- with oil of rose.
nate years. (See VIRUS.)
Creatine
CPR A nitrogenous substance, methyl-guanidine-
See CARDIOPULMONARY RESUSCITATION (CPR). acetic acid. The adult human body contains
about 120 grams 98 per cent of which is in
Crab-Louse the muscles. Much of the creatine in muscles is
Another name for Pediculus pubis, a louse that combined with phosphoric acid as phospho-
infests the pubic region. (See PEDICULOSIS.) creatine, which plays an important part in the
chemistry of muscular contraction.
Cracked-Pot Sound
A peculiar resonance heard sometimes on per- Creatine Kinase
cussion of the chest over a cavity in the lung, An ENZYME which is proving to be of value in
resembling the jarring sound heard on striking the investigation and diagnosis of muscular dys-
a cracked pot or bell. It is also heard on per- trophy (see MUSCLES, DISORDERS OF Myopa-
cussion over the skull in patients with diseases thy), in which it is found in the blood in greatly
of the brain such as haemorrhages and increased amounts.
tumours, and in certain cases of fracture of the
skull. Creatinine
Creatinine is the anhydride of CREATINE and is
Cradle derived from it. It is a metabolic waste product.
A cage which is placed over the legs of a patient
in bed, in order to take the weight of the Creatinine Clearance
bedclothes off the legs. A method of assessing the function of the kid-
ney (see KIDNEYS) by comparing the amount of
Cradle Cap creatinine a product of body metabolism
Crusta lactea, or cradle cap as it is technically which is normally excreted by the kidneys in
known, is a form of SEBORRHOEA of the scalp the blood with the amount appearing in the
which is not uncommon in nursing infants. It urine.
 170 Creeping Eruption

Creeping Eruption THYROIDISM, a disease caused by defective thy-

Creeping eruption is a skin condition caused by roid function in fetal life or early in infancy.
the invasion of the skin by the larvae of various
species of nematode worms. It owes its name to Creutzfeldt-Jakob Disease (CJD)
the fact that as the larva moves through and A rapidly progressive, fatal, degenerative disease
C along the skin it leaves behind it a long creeping in humans caused by an abnormal PRION pro-
thin red line. (See STRONGYLOIDIASIS.) tein. There are three aetiological forms of CJD:
sporadic, IATROGENIC, and inherited. Sporadic
Cremation CJD occurs randomly in all countries and has
See DEAD, DISPOSAL OF THE. an annual incidence of one per million. Iatro-
genic CJD is caused by accidental exposure to
Crenation human prions through medical and surgical
Abnormal microscopic appearance of blood procedures (and cannibalism in the case of the
cells in which their usually smooth margins human prion disease known as kuru that occurs
appear irregular. It usually occurs after a blood in a tribe in New Guinea, where it is called the
specimen has been stored for a long time, but trembling disease). Inherited or familial CJD
may occasionally indicate a blood disorder. accounts for 15 per cent of human prion disease
and is caused by a MUTATION in the prion pro-
Creosote tein gene. In recent years a new variant of CJD
A clear, yellow liquid, of aromatic smell and has been identified that is caused by BOVINE
burning taste, prepared by distillation from SPONGIFORM ENCEPHALOPATHY (BSE), called
pine-wood or beech-wood. It mixes readily with variant CJD. The incubation period for the
alcohol, ether, chloroform, glycerin, and oils. acquired varieties ranges from four years to 40
Creosote is a powerful antiseptic and dis- years, with an average of 1015 years. The
infectant; it is also an ingredient of some dis- symptoms of CJD are dementia, seizures, focal
infectant fluids. signs in the central nervous system, MYO-
CLONUS, and visual disturbances.
Crepitations Abnormal prion proteins accumulate in the
Certain sounds which occur along with the brain and the spinal cord, damaging neurones
breath sounds, as heard by AUSCULTATION, in (see NEURON(E)) and producing small cavities.
various diseases of the LUNGS. They are signs of Diagnosis can be made by tonsil (see TONSILS)
the presence of moist exudations in the lungs or biopsy, although work is under way to develop a
in the bronchial tubes, are classified as fine, diagnostic blood test. Abnormal prion proteins
medium, and coarse crepitations, and resemble are unusually resistant to inactivation by chem-
the sound made by bursting bubbles of various icals, heat, X-RAYS or ULTRAVIOLET RAYS (UVR).
sizes. They are resistant to cellular degradation and
can convert normal prion proteins into
Crepitus abnormal forms. Human prion diseases, along
Crepitus means a grating sound. It is found in with scrapie in sheep and BSE in cattle, belong
cases of fractured bones when the ends rub to a group of disorders known as transmissible
together; also, in cases of severe chronic arth- spongiform encephalopathies. Abnormal prion
ritis, by the rubbing together of the dried proteins can transfer from one animal species to
internal surfaces of the joints. another, and variant CJD has occurred as a
result of consumption of meat from cattle
Cresol infected with BSE.
An oily liquid obtained from coal tar. It is a From 1995 to 1999, a scientific study of ton-
powerful antiseptic and disinfectant. sils and appendixes removed at operation sug-
gested that the prevalence of prion carriage may
Uses Cresol is used combined with soap to be as high as 120 per million. It is not known
form a clear saponaceous fluid known as lysol, what percentage of these might go on to
which can be mixed with water in any propor- develop disease.
tions. For the disinfection of drains it is used at One precaution is that, since 2003, all surgi-
a dilution of one in 20; for heavily infected cal instruments used in brain biopsies have had
linen, one in 40; and for floors and walls, one in to be quarantined and disposable instruments
100. are now used in tonsillectomy.
Measures have also been introduced to
Cretinism reduce the risk of transmission of CJD from
An out-of-date name for congenital HYPO- transfusion of blood products.
 Crohns Disease 171

In the past, CJD has also been acquired from occurs in people over 70 years of age. Both gen-
intramuscular injections of human cadaveric etic and environmental factors are implicated in
pituitary-derived growth hormone and corneal the disease for example, if one identical twin
transplantation. develops the disease, the second twin stands a
The most common form of CJD remains the high chance of being affected; and 10 per cent
sporadic variety, although the eventual inci- of sufferers have a close relative with inflamma- C
dence of variant CJD may not be known for tory bowel disease. Among environmental fac-
many years. tors are low-residue, high-refined-sugar diets,
and smoking.
Crisis Symptoms and signs of Crohns disease
Crisis is a word used with several distinct mean- depend on the site affected but include abdom-
ings. (1) The traditional meaning is that of a inal pain, diarrhoea (sometimes bloody), ANO-
rapid loss of fever and return to comparative REXIA, weight loss, lethargy, malaise, ANAEMIA,
health in certain acute diseases. For example, and sore tongue and lips. An abdominal mass
PNEUMONIA, if allowed to run its natural may be present. Complications can be severe,
course, ends by a crisis usually on the eighth day, including life-threatening inflammation of the
the temperature falling in 24 hours to normal, colon (which may cause TOXAEMIA), perfor-
the pulse and breathing becoming slow and ation of the colon and the development of fistu-
regular and the patient passing from a partly lae between the bowel and other organs in the
delirious state into natural sleep. In this sense of abdomen or pelvis. If Crohns disease persists
the word, the opposite of crisis is lysis: for for a decade or more there is an increased risk of
example, in typhoid fever (see ENTERIC FEVER), the victim developing colon cancer. Extensive
where the patient slowly improves during a investigations are usually necessary to diagnose
period of a week or more, without any sudden the disease; these include blood tests, bacterio-
change. (2) A current use of the word crisis, and logical studies, ENDOSCOPY and biopsy, and
still more frequently of critical, is to signify a barium X-ray examinations.
dangerous state of illness in which it is uncertain
whether the sufferer will recover or not. Treatment As with ulcerative colitis, treat-
ment is aimed primarily at controlling symp-
Crohns Disease toms. Physicians, surgeons, radiologists and
A chronic inflammatory bowel disease which dietitians usually adopt a team approach, while
has a protracted, relapsing and remitting counsellors and patient support groups are
course. An autoimmune condition, it may last valuable adjuncts in a disease that is typically
for several years. There are many similarities lifelong. Drug treatment is aimed at settling the
with ULCERATIVE COLITIS; sometimes it can be acute phase and preventing relapses. CORTICO-
hard to differentiate between the two condi- STEROIDS, given locally to the affected gut or
tions. A crucial difference is that ulcerative col- orally, are used initially and the effects must be
itis is confined to the colon (see INTESTINE), carefully monitored. If steroids do not work,
whereas Crohns disease can affect any part of the immunosuppressant agent AZATHIOPRINE
the gastrointestinal tract, including the mouth should be considered. Antidiarrhoeal drugs may
and anus. The sites most commonly affected in occasionally be helpful but should not be taken
Crohns disease (in order of frequency) are ter- during an acute phase. The anti-inflammatory
minal ILEUM and right side of colon, just the drug SULFASALAZINE can be beneficial in mild
colon, just the ileum and finally the ileum and colitis. A new generation of genetically engin-
JEJUNUM. The whole wall of the affected bowel eered anti-inflammatory drugs is now available,
is oedamatous (see OEDEMA) and thickened, and these selective immunosuppressants may
with deep ulcers a characteristic feature. Ulcers prove of value in the treatment of Crohns
may even penetrate the bowel wall, with disease.
abscesses and fistulas developing. Another Diet is important and professional guidance
unusual feature is the presence in the affected is advisable. Some patients respond to milk- or
bowel lining of islands of normal tissue. wheat-free diets, but the best course for most
Crohns disease is rare in the developing patients is to eat a well-balanced diet, avoiding
world, but in the western world the incidence is items that the sufferer knows from experience
increasing and is now 67 per 100,000 popula- are poorly tolerated. Of those patients with
tion. Around 80,000 people in the UK have the extensive disease, as many as 80 per cent may
disorder with more than 4,000 new cases occur- require surgery to alleviate symptoms: a section
ring annually. Commonly Crohns disease starts of affected gut may be removed or, as a life-
in young adults, but a second incidence surge saving measure, a bowel perforation dealt with.
 172 Crotamiton

(See APPENDIX 2: ADDRESSES: SOURCES OF CRP

INFORMATION, ADVICE, SUPPORT AND SELF- Stands for C-Reactive Protein, and refers to a
HELP Colitis; Crohns disease.) blood measurement which is a marker of
inflammation so offering a clue as to whether
Crotamiton infection might be present or, in inflammatory
C A topical cream used to treat pruritus (itch). illnesses, being used to track the progress of the
condition.
Crotch
See PERINEUM. Cruciate Ligaments
Two strong ligaments in the interior of the
Croup knee-joint, which cross one another like the
Also known as laryngo-tracheo-bronchitis, limbs of the letter X. They are so attached as to
croup is a household term for a group of dis- become taut when the lower limb is straight-
eases characterised by swelling and partial ened, and they prevent over-extension or bend-
blockage of the entrance to the LARYNX, occur- ing forwards at the knee. The cruciate liga-
ring in children and characterised by crowing ments are sometimes strained or torn as a
inspiration. There are various causes but by far result of sporting injuries or vehicular acci-
the commonest is acute laryngo-tracheo- dents; surgery may be needed to repair the
bronchitis (see under LARYNX, DISORDERS OF). damage, but the knee will be permanently
Croup tends to occur in epidemics, particularly weakened.
in autumn and early spring, and is almost
exclusively viral in origin commonly due to Crural
parainfluenza or other respiratory viruses. It is Crural means connected with the leg.
nearly always mild and sufferers recover spon-
taneously; however, it can be dangerous, par-
ticularly in young children and infants, in Crush Syndrome
whom the relatively small laryngeal airway may A condition in which kidney failure occurs in
easily be blocked, leading to suffocation. patients who have been the victims of severe
crushing accidents (see also KIDNEYS). The fun-
Symptoms Attacks generally come on at damental injury is damage to muscle. The limb
night, following a cold caught during the previ- swells. The blood volume falls. Blood UREA
ous couple of days. The breathing is hoarse and rises; there is also a rise in the POTASSIUM con-
croaking (croup), with a barking cough and tent of the blood. Urgent treatment in an inten-
harsh respiratory noise. The natural tendency sive therapy unit is required and renal dialysis
for the laryngeal airway to collapse is increased may well be necessary. The patient may survive;
by the childs desperate attempts to overcome or die with renal failure. Post-mortem examin-
the obstruction. Parental anxiety, added to that ation shows degeneration of the tubules of the
of the child, only exacerbates the situation. kidney, and the presence in them of pigment
After struggling for up to several hours, the casts.
child finally falls asleep. The condition may
recur. Crusta Lactea
See CRADLE CAP.
Treatment Most children with croup should
be looked after at home if the environment is Crutch
suitable. Severe episodes may require hospital (1) An aid to support the weight of the body
observation, with treatment by oxygen if for a person unable to bear weight on one of his
needed and usually with a single dose of inhaled or her legs. Made of wood or metal, usually
steroid or oral PREDNISONE. For the very few long enough to reach from the persons armpit
children whose illness progresses to respiratory to the ground, it has a concave surface that fits
obstruction, intubation and ventilation may be under the arm and a cross-bar for the hand. An
needed for a few days. There is little evidence elbow crutch provides weight-bearing support
that putting the child in a mist tent or giving using the forearm and elbow and is usually
antibiotics is of any value. Of greater import- recommended when the leg can take some
ance is the reassurance of the child, and careful weight.
observation for signs of deterioration, together (2) See PERINEUM.
with the exclusion of other causes such as
foreign-body inhalation and bacterial Crutch Palsy
tracheitis. Crutch palsy is weakness or paralysis of muscles
 CS Gas 173

in the wrist and hand, due to pressure exerted two main forms in which it is now used are
by the CRUTCH head on the nerves that control HYPOTHERMIA and refrigeration ANAESTHESIA.
the affected muscles. It usually occurs because
the crutch is too long for the individual, and/or Cryptococcosis
if he or she attempts too much walking. The Cryptococcosis is a rare disease due to infection
nerve damage is temporary and symptoms dis- with a yeast known as Cryptococcus neoformans. C
appear if the crutch is properly used or left aside Around 510 cases are diagnosed annually in
for a time. the United Kingdom. It usually involves the
lungs in the first instance, but may spread to the
Cryoanalgesia MENINGES and other parts of the body, includ-
The induction of analgesia (see ANALGESICS) by ing the skin. As a rule, the disease responds well
the use of cold that is produced by means of a to treatment with AMPHOTERICIN B, clotrima-
special probe. The use of cold for the relief of zole, and flucytosine.
pain dates back to the early days of mankind:
two millennia ago, Hippocrates was recom- Cryptococcus
mending snow and ice packs as a preoperative A genus of yeasts. Cryptococcus neoformans is
analgesic. The modern probe allows a precise widespread in nature, and is present in particu-
temperature to be induced in a prescribed area. larly large numbers in the faeces of pigeons. It
Among its uses is in the relief of chronic pain occasionally infects humans, as a result of the
which will not respond to any other form of inhalation of dust contaminated by the faeces of
treatment. This applies particularly to chronic pigeons causing the disease known as
facial pain. CRYPTOCOCCOSIS.

Cryoprecipitate Cryptorchidism
When frozen plasma is allowed to thaw slowly An undescended testis (see TESTICLE). The tes-
at 4 C, a proportion of the plasma protein tes normally descend into the scrotum during
remains undissolved in the cold thawed plasma the seventh month of gestation; until then, the
and stays in this state until the plasma is testis is an abdominal organ. If the testes do
warmed. It is this cold, insoluble precipitate not descend before the first year of life, they
that is known as cryoprecipitate. It can be usually remain undescended until puberty
recovered quite easily by centrifuging. Its value and even then, descent is not achieved in some
is that it is a rich source of factor VIII, which is instances. Fertility is impaired when one testis
used in the treatment of HAEMOPHILIA. is affected and is usually absent in the bilateral
cases. The incidence of undescended testis in
Cryopreservation full-term children at birth is 35 per cent, fall-
Maintenance at very low temperatures of the ing to less than 2 per cent at one month and
viability of tissues or organs that have been 07 per cent at one year. Because of the high
excised from the body. risk of infertility, undescended testes should be
brought down as early as possible and at the
Cryoscopy latest by the age of two. Sometimes medical
The method of finding the concentration of treatment with HUMAN CHORIONIC GONADO-
blood, urine, etc., by observing their freezing- TROPHIN is helpful but frequently surgical
point. interference is necessary. This is the operation
of orchidopexy.
Cryosurgery
The use of cold in surgery. Its advantages CSF
include little associated pain, little or no bleed- See CEREBROSPINAL FLUID.
ing, and excellent healing with little or no scar
formation. Hence its relatively wide use in eye CS Gas
surgery, some abdominal surgery, skin cancers A noxious gas used for riot control which causes
and treatment of HAEMORRHOIDS. The cool- irritation of the eyes and respiratory tract.
ants used include liquid nitrogen with which Symptoms usually subside within 20 minutes
temperatures as low as 196 C can be but, if they persist, the victim should be
obtained, carbon dioxide (78 C) and nitrous removed to a well-ventilated area, contaminated
oxide (88 C). clothing removed, the affected skin washed
with soap and water and the eyes irrigated with
Cryotherapy water or physiological saline. (CONTACT LENSES
The treatment of disease by refrigeration. The should be removed and washed, if hard; dis-
 174 CSM

carded, if soft.) If respiratory complications Cuticle

develop, the victim should be admitted to See SKIN.
hospital.
Cuts
CSM See WOUNDS.
C See COMMITTEE ON SAFETY OF MEDICINES
(CSM). Cyanide Poisoning
Cyanide inhibits cellular RESPIRATION by bind-
CT Scan ing rapidly and reversibly with the ENZYME,
See COMPUTED TOMOGRAPHY. cytochrome oxidase. Effects of poisoning are
due to tissue HYPOXIA. Cyanide is toxic by
CT Scanner inhalation, ingestion and prolonged skin con-
The machine which combines the use of a tact, and acts extremely quickly once absorbed.
computer and X-rays to produce cross-sectional Following inhalation of hydrogen cyanide gas,
images of the body (see COMPUTED death can occur within minutes. Ingestion of
TOMOGRAPHY). inorganic cyanide salts may produce symptoms
within 10 minutes, again proceeding rapidly to
Culdoscopy death. On a full stomach, effects may be
Culdoscopy is a method of examining the pel- delayed for an hour or more. Signs of cyanide
vic organs in women by means of an instrument poisoning are headache, dizziness, vomiting,
comparable to a CYSTOSCOPE, inserted into the weakness, ATAXIA, HYPERVENTILATION, DYS-
pelvic cavity through the VAGINA. The instru- PNOEA, HYPOTENSION and collapse. Loss of
ment used for this purpose is known as a vision and hearing may occur, then COMA and
culdoscope. CONVULSIONS. Other features include cardiac
ARRHYTHMIA and PULMONARY OEDEMA.
Curette Patients may have a lactic ACIDOSIS. Their
A spoon-shaped instrument with a cutting arterial oxygen tension is likely to be normal,
edge, used for scooping out the contents of any but their venous oxygen tension high and simi-
body cavity for example, the uterus or lar to that of arterial blood.
for removing certain skin lesions, such as
verrucae. Treatment Administration of oxygen when
available is the most important first-aid man-
Cushings Syndrome agement. Rescuers should be trained, must not
Described in 1932 by Harvey Cushing, the put themselves at risk, and should use protect-
American neurosurgeon, Cushings syndrome is ive clothing and breathing apparatus. In
due to an excess production of CORTISOL. It can unconscious victims, establish a clear airway
thus result from a tumour of the ADRENAL and give 100 per cent oxygen. If breathing stops
GLANDS secreting cortisol, or from a PITUITARY and oxygen is unavailable, initiate expired-air
GLAND tumour secreting ACTH and stimulating resuscitation. If cyanide salts were ingested,
both adrenal cortexes to hypertrophy and mouth-to-mouth contact must be avoided and
secrete excess cortisol. It is sometimes the result a mask with a one-way valve employed instead.
of ectopic production of ACTH from non- Some commercially available first-aid kits con-
endocrine tumours in the LUNGS and PANCREAS. tain AMYL NITRATE as an antidote which may be
The patient gains weight and the obesity employed if oxygen is unavailable.
tends to have a characteristic distribution over Once in hospital, or if a trained physician is
the face, neck, and shoulder and pelvic girdles. on the scene, then antidotes may be adminis-
Purple striae develop over the abdomen and tered. There are several different intravenous
there is often increased hairiness or hirsutism. antidotes that may be used either alone or in
The blood pressure is commonly raised and the combination. In mild to moderate cases,
bone softens as a result of osteoporosis. The sodium thiosulphate is usually given. In more
best test to establish the diagnosis is to measure severe cases either dicobalt edetate or sodium
the amount of cortisol in a 24-hourly specimen nitrite may be used, followed by sodium thio-
of urine. Once the diagnosis has been estab- sulphate. Some of these (e.g. dicobalt edetate)
lished, it is then necessary to undertake further should be given only where diagnosis is certain,
tests to determine the cause. otherwise serious adverse reations or toxicity
due to the antidotes may occur.
Cutaneous
Cutaneous means belonging to the SKIN.
 Cyesis 175

Cyanides mocriptine, a dopamine agonist, may improve

Salts of hydrocyanic or prussic acid. They are the oedema.
highly poisonous, and are also powerful anti-
septics. (See CYANIDE POISONING; WOUNDS.) Cyclizine Hydrochloride
One of the ANTIHISTAMINE DRUGS which is
Cyanocobalamin mainly used for the prevention of sickness, C
The name given by the British Pharmacopoeia including sea-sickness.
Commission to vitamin B12, found to be an
effective substitute for liver in the treatment of
pernicious ANAEMIA. It has now been replaced Cyclo-Oxygenase-2 Selective
by HYDROXOCOBALAMIN as the standard Inhibitors
treatment for this condition (see also See COX-2 INHIBITORS.
COBALAMINS).
Cyclophosphamide
Cyanosis A derivative of NITROGEN MUSTARDS used to
A condition in which the skin usually of treat various forms of malignant disease,
the face and extremities takes on a bluish including HODGKINS DISEASE and chronic
tinge. It accompanies states in which the lymphocytic LEUKAEMIA. (See also ALKYLATING
blood is not properly oxygenated in the lungs, AGENTS; CYTOTOXIC.)
and appears earliest through the nails, on the
lips, on the tips of the ears, and over the
cheeks. It may be due to blockage of the air Cycloplegia
passages, or to disease in the lungs, or to a Paralysis of the ciliary muscle of the EYE, which
feeble circulation, as in heart disease. (See results in the loss of the power of ACCOM-
MODATION in the eye.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
(COPD); METHAEMOGLOBINAEMIA.)
Cyclopropane
Cybernetics One of the most potent of the anaesthetics
The science of communication and control in given by inhalation (see ANAESTHESIA). Its
the animal and in the machine. advantages are that it acts quickly, causes little
irritation to the lungs, and its effects pass off
Cyclamates quickly.
Artificial sweetening agents which are about 30
times as sweet as cane sugar. After being in use Cycloserine
since 1965, they were banned by government
An antibiotic derived from an actinomycete,
decree in 1969 because of adverse reports
used to treat certain infections of the genito-
received from the USA.
urinary tract, and and in combination with
other drugs to treat TUBERCULOSIS resistant to
Cyclical Oedema first-line drugs.
This is a syndrome in women, characterised by
irregular intermittent bouts of generalised swell-
ing. Sometimes the fluid retention is more pro- Cyclothymia
nounced before the menstrual period (see MEN- The state characterised by extreme swings of
STRUATION). The eyelids are puffy and the face mood from elation to depression, and vice
and fingers feel stiff and bloated. The breasts versa. (See also MANIC DEPRESSION; MENTAL
may feel swollen and the abdomen distended, ILLNESS.)
and ankles may swell. The diurnal weight gain
may exceed 4 kg. The underlying disturbance Cyclotron
is due to increased loss of fluid from the vascu- A machine in which positively charged atomic
lar compartment, probably from leakage of particles are so accelerated that they acquire
protein from the capillaries increasing the tis- energies equivalent to those produced by mil-
sue osmotic pressure. Recent evidence suggests lions of volts. From the medical point of view,
that a decrease in the urinary excretion of its interest is that it is a source of neutrons. (See
DOPAMINE may contribute, as this has a natri- RADIOTHERAPY.)
uretic action (see NATRIURESIS). This may
explain why drugs that are dopamine antagon- Cyesis
ists, such as chlorpromazine, may precipitate or Another term for pregnancy (see PREGNANCY
aggravate cyclical oedema. Conversely, bro- AND LABOUR).
 176 Cyproterone Acetate

Cyproterone Acetate to a greater degree in the muscles than the

An antiandrogen. It inhibits the effects of brain, allowing them to be seen radiologically.
androgens (see ANDROGEN) at receptor level and Epilepsy starting in adult life, in anyone who
is therefore useful in the treatment of prostate has previously lived in an endemic area, should
cancer (see PROSTATE, DISEASES OF), ACNE, HIR- suggest the possibility of cysticercosis. (See also
C SUTISM in women and in the treatment of TAENIASIS.)
severe hypersexuality and sexual deviation in
men. The drug can have serious side-effects. (See Treatment Most important is prevention of
OESTROGENS.) the initial tapeworm infection, by ensuring that
pork is well cooked before it is eaten. Nurses
Cystectomy and others attending to a patient harbouring
The surgical excision of the bladder (see URIN- an adult tapeworm must be careful to avoid
ARY BLADDER). When this is done usually to ingesting ova from contaminated hands. The
treat cancer of the bladder an alternative tapeworm itself can be destroyed with NICLOSA-
means of collecting urine from the KIDNEYS MIDE. Brain infections are treated with seda-
must be arranged. The URETERS of the kidney tives and anti-convulsants, surgery rarely being
can be transplanted into a loop of bowel which necessary. Most patients make a good recovery.
is brought to the surface of the abdomen to
form a STOMA that exits into an externally worn Cystic Fibrosis
pouch. The latest surgical technique is to fash- This is the most common serious genetic dis-
ion a substitute bladder from a section of intes- ease in Caucasian children, with an incidence of
tine and to implant the ureters into it, thus about one per 2,500 births, and more than
allowing the patient to void urine through the 6,000 patients in the UK (30,000 in the USA).
urethra as normal. It is an autosomal recessive disorder of the
mucus-secreting glands of the lungs, the pan-
Cysteine creas, the mouth, and the gastrointestinal tract,
An amino acid containing SULPHUR that is an as well as the sweat glands of the skin. The
essential constituent of many of the bodys defective gene is sited on chromosome 7 which
enzymes. (See AMINO ACIDS; ENZYME.) encodes for a protein, cystic fibrosis transmem-
brane conductance regulator (CFTR). Indi-
viduals who inherit the gene only on one set of
Cystic Duct chromosomes can, however, carry the defect
The tube that runs from the gall-bladder (see into successive generations. Where parents have
LIVER) and joins up with the hepatic duct
a child with cystic fibrosis, they have a one-in-
(formed from the bile ducts) to form the com- four chance of subsequent children having the
mon BILE DUCT. The BILE produced by the liver disease. They should seek GENETIC
cells is drained through this system and enters COUNSELLING.
the small intestine to help in the digestion of The disorder is characterised by failure to
food. gain weight in spite of a good appetite, by
repeated attacks of bronchitis (with BRON-
Cysticercosis CHIECTASIS developing at a young age), and by
This disease rarely occurs except in Central the passage of loose, foul-smelling and slimy
Europe, Ethiopia, South Africa, and part of stools (faeces). AMNIOCENTESIS, which yields
Asia. It results from ova (eggs) being swallowed amniotic fluid along with cells shed from the
or regurgitated into the stomach from an adult fetuss skin, can be used to diagnose cystic
pork tapeworm in the intestine. In the stomach fibrosis prenatally. The levels of various
the larvae escape from the eggs and are enzymes can be measured in the fluid and are
absorbed. They are carried in the blood to vari- abnormal when the fetus is affected by cystic
ous parts of the body, most commonly the sub- fibrosis. Neonatal screening is possible using a
cutaneous tissue and skeletal muscle, where test on blood spots immunoreactive trypsin
they develop and form cysticerci. When super- (IRT).
ficial, they may be felt under the skin as small In children with symptoms or a positive fam-
pea-like bodies. Although they cause no symp- ily history, the disease can be tested for by
toms here, cysts may also develop in the brain. measuring sweat chloride and sodium. This
Five years later the larvae die, and the brain- detects the abnormal amount of salt that is
tissue reaction may result in epileptic fits, excreted via the sweat glands when cystic fibro-
obscure neurological disorders, and personality sis is present. Confirmation is by genetic
changes. The cysts calcify at this stage, though testing.
 Cysts 177

Treatment This consists basically of regular relevant antibiotic can then be prescribed.
physiotherapy and postural drainage, anti- Fluids should be taken freely not only for an
biotics and the taking of pancreatic enzyme tab- acute attack of cystitis but also to prevent fur-
lets and vitamins. Some children need STEROID ther attacks, because if the urine is dilute the
treatment and all require nutritional support. organism is less likely to grow. Bicarbonate of
The earlier treatment is started, the better the soda is also helpful as this reduces the acidity of C
results. Whereas two decades ago, only 12 per the urine and helps to relieve the burning pain,
cent of affected children survived beyond ado- and inhibits the growth of the bacteria. Careful
lescence, today 75 per cent survive into adult hygiene, in order to keep the PERINEUM clean,
life, and an increasing number are surviving is also important. (See URINARY BLADDER, DIS-
into their 40s. Patients with end-stage disease EASES OF.)
can be treated by heart-lung transplantation
(with their own heart going to another recipi- Cystocoele
ent). Research is underway on the possible use A PROLAPSE of the base of the URINARY BLAD-
of GENE THERAPY to control the disorder. Par- DER in a woman. The pelvic floor muscles may
ents of children with cystic fibrosis, seeking be weakened after childbirth and, when the
help and advice, can obtain this from the Cystic woman strains, the front wall of the vagina
Fibrosis Trust. bulges. Stress incontinence often accompanies a
cystocoele and surgical repair is then advisable
Cystitis (see COLPORRHAPHY).
Inflammation of the URINARY BLADDER. The
presenting symptom is usually dysuria that is, Cystogram
a feeling of discomfort when urine is passed and An X-ray picture of the URINARY BLADDER.
frequently a stinging or burning pain in the
URETHRA. There is also a feeling of wanting to Cystometer
pass water much more often than usual, even An instrument for measuring the pressure in
though there is very little urine present when the URINARY BLADDER.
the act is performed. The condition may be
associated with a dragging ache in the lower Cystometry
abdomen, and the urine usually looks dark or A technique for measuring the pressure in the
stronger than normal. It is frequently associated URINARY BLADDER as part of a URODYNAMIC
with haematuria, which means blood in the investigation to assess the functioning of the
urine and is the result of the inflammation. bladder.
Cystitis is a common problem; more than
half the women in Britain suffer from it at Cystoscope
some time in their lives. The cause of the dis- An instrument for viewing the interior of the
ease is a bacterial infection of the bladder, the URINARY BLADDER. It consists of a narrow tube
germs having entered the urethra and ascended carrying a small electric lamp at its end; a small
into the bladder. The most common organism mirror set obliquely opposite an opening near
responsible is called Escherichia coli. This the end of the tube; and a telescope which is
organism normally lives in the bowel where it passed down the tube and by which the reflec-
causes no harm. It is therefore likely to be tion of the brightly illuminated bladder wall in
present on the skin around the anus so that the mirror is examined. It is of great value in the
there is always a potential for infection. The diagnosis of conditions like ulcers and small
disease is much more common in women tumours of the bladder.
because the urethra, vagina and anus are very Fine CATHETERS can be passed along the
close together and the urethra is much shorter cystoscope, and by the aid of vision can be
in the female than it is in the male. It also inserted into each ureter and pushed up to the
explains why women commonly suffer cystitis kidney, so that the urine from each kidney may
after sexual intercourse and honeymoon cyst- be obtained and examined separately in order to
itis is a very common presentation of bladder diagnose which of these organs is diseased.
inflammation. In most cases the inflammation
is more of a nuisance than a danger but the Cysts
infection can spread up to the kidneys and Hollow tumours (see TUMOUR), containing
cause PYELITIS which is a much more serious fluid or soft material. They are almost always
disorder. simple in nature.
In cases of cystitis the urine should be cul-
tured to grow the responsible organism. The Retention cysts In these, in consequence of
 178 Cytarabine

irritation or another cause, some cavity which cells of the body, with particular reference to
ought naturally to contain a little fluid becomes the CHROMOSOMES.
distended, or the natural outlet from the cavity
becomes blocked. Wens are caused by the Cytokines
blockage of the outlet from sebaceous glands in A family of PROTEIN molecules that carry sig-
C the skin, so that an accumulation of fatty mat- nals locally between cells. Cytokines are released
ter takes place. RANULA is a clear swelling under by cells when activated by antigens (see ANTI-
the tongue, due to a collection of saliva in con- GEN), behaving as enhancing mediators for
sequence of an obstruction to a salivary duct. immune response. These proteins include
Cysts in the breasts are, in many cases, the result INTERLEUKINS (produced by LEUCOCYTES),
of blockage in milk ducts, due to inflammation; lymphokines (produced by lymphocytes see
they should be assessed to exclude cancer (see LYMPHOCYTE), INTERFERON, and tumour
BREASTS, DISEASES OF). Cysts also form in the necrosis factor, one of whose many functions is
kidney as a result of obstruction to the free out- killing tumour cells.
flow of the urine.
Cytology
Developmental cysts Of these, the most The study of CELLS.
important are the huge cysts that originate in
the OVARIES. The cause is doubtful, but the cyst Cytomegalovirus (CMV)
probably begins at a very early period of life, A commonly occurring virus of the herpes virus
gradually enlarges, and buds off smaller cysts group the name derived from the swollen
from its wall. The contents are usually a clear appearance of infected cells (cytomegalo =
gelatinous fluid. Very often both ovaries are large cell). The infection is usually asymptom-
affected, and the cysts may slowly reach a great atic (or like mild influenza), but it can cause an
size often, however, taking a lifetime to do so. illness similar to infectious MONONUCLEOSIS.
A similar condition sometimes occurs in the Most people (80 per cent) will have had CMV
KIDNEYS, and the tumour may have reached a infection by the time they are adults, but the
great size in an infant even before birth (con- virus can remain latent in the body and cause
genital cystic kidney). recurrent infections. During an acute infection
Dermoid cysts are small cavities, which also the virus is excreted in saliva, breast milk and
originate probably early in life, but do not reach urine as well as from the vagina, and this may
any great size until fairly late in life. They continue for years. CMV is transmitted natur-
appear about parts of the body where clefts ally by saliva or during sexual contact, but
occur in the embryo and close up before birth, blood transfusions and organ transplantations
such as the corner of the eyes, the side of the are also infection routes. Although CMV rarely
neck, and the middle line of the body. They causes its host any problems, when it is passed
contain hair, fatty matter, fragments of bone, from an infected mother to her fetus in utero or
scraps of skin, even numerous teeth. to an infant during birth (from vaginal secre-
tions) or via breast milk postnatally, the virus
Hydatid cysts are produced in many causes a generalised severe infection in the
organs, particularly in the liver, by a parasite infant. This can involve the central nervous
which is the larval stage of a tapeworm found in system and liver, causing death of the fetus or
dogs. They occur in people who keep dogs and neonate. If the infant survives it may be
allow them to contaminate their food. (See mentally retarded, with motor disabilities,
TAENIASIS.) deafness and chronic liver disease. In England
and Wales about 400 babies a year are born
Cytarabine with CMV-induced disabilities. If an adult is
An drug used mainly to induce remission of immunodeficient (see IMMUNODEFICIENCY)
acute myeloblastic LEUKAEMIA. A potent sup- because of HIV infection/AIDS or as a result of
pressant of myeloblasts, its use requires moni- immunosuppressive treatment after an organ
toring by a HAEMATOLOGIST. (See CYTOTOXIC.) transplant, he or she may become seriously ill.

Cyto- Cytometer
A prefix meaning something connected with a An instrument for counting and measuring
cell or CELLS. CELLS.

Cytogenetics Cytoplasm
The study of the structure and functions of the The PROTOPLASM of the cell body. (See CELLS.)
 Cytotoxic 179

Cytotoxic (2) There are a number of cytotoxic antibiotics

Cytotoxic means destructive to living cells. Cyto- used in the treatment of cancer doxorubicin,
toxic drugs possess anti-cancer properties but bleomycin, dactinomycin, mithramycin and
also have the potential to damage normal tissue. amsacrine are examples. They are used primar-
Their use is twofold: to eliminate a cancer and so ily in the treatment of acute leukaemia and
prolong life; or to alleviate distressing symptoms, lymphomas. C
especially in patients whose prospects of a cure (3) Antimetabolites these drugs combine
are poor. In many cases CHEMOTHERAPY with irreversibly with vital enzyme systems of the cell
cytotoxic drugs is combined with surgery, and hence prevent normal cell division. Meth-
RADIOTHERAPY or both. Chemotherapy may be otrexate, cytarabine, fluorouracil, mercaptopu-
used initially to reduce the size of the primary rine and azathioprine are examples.
TUMOUR (a process called neoadjuvant therapy) (4) Another group of cytotoxic drugs are the
before using radiotherapy or surgery to eliminate vinca alkaloids such as vincristine, vinblastine
it. Cytotoxic drugs may also be used as adjuvant and vindesima.
treatment to prevent or destroy secondary (5) Platinum compounds such as carboplatin,
spread of the primary tumour that has either cisplatin and oxaliplatin are effective. All of
been removed by surgery or treated with radio- them are given intravenously, but the latter
therapy. All chemotherapy causes side-effects: two tend to have more unpleasant side-effects.
the ONCOLOGIST a specialist in cancer treat- Carboplatin and cisplatin are useful in the
ment has to strike a balance between hoped- treatment of solid tumours. Carboplatin, a
for benefits and acceptable (for the patient) derivative of cisplatin, is given intravenously in
toxic effects, which include nausea and vomit- ovarian cancer and in small-cell lung cancer.
ing, BONE MARROW suppression, ALOPECIA Better tolerated than cisplatin, the drug causes
(hair loss) and teratogenic effects (see less nausea and vomiting, nephrotoxicity, neu-
TERATOGENESIS). rotoxicity and ototoxicity. Where platinum-
Cytotoxic drugs are used either singly or in containing therapy has failed, intravenous
combination, when an enhanced response is the treatment with paclitaxel may be tried. With
aim. Chemotherapy of cancer is a complex pro- only a limited success rate, it is relatively toxic
cess and should be supervised by an oncologist and should be carefully supervised; responses,
in co-operation with physicians, surgeons, however, are sometimes prolonged.
radiotherapists and radiologists as appropriate. Also of increasing importance in treating
The cytotoxic drugs include: cancer are interferons. These are naturally
(1) The alkylating agents which act by occurring proteins with complex effects on
damaging DNA, thus interfering with cell immunity and cell function. Although toxic,
reproduction. Cyclophosphamide, ifosfamide, with numerous adverse effects, they have shown
chlorambucil, kelphalan, busulphan, thiotepa some anti-tumour effect against certain lymph-
and mustine are examples of alkylating agents. omas and solid tumours.
 spasm. It may cause drowsiness, resulting in

D impaired performance at skilled tasks and

driving.

Dapsone
One of the most effective drugs in the treat-
ment of LEPROSY. An antibacterial drug, its use
D and C may cause nausea and vomiting; occasionally, it
See DILATATION AND CURETTAGE. may harm nerves, the liver, and red blood cells.
During treatment, blood tests are done to check
Da Costas Syndrome on liver function and the number of red cells in
See EFFORT SYNDROME. the blood.
The drug is also used to treat dermatitis her-
Dacryocystitis petiformis, a rare skin disorder.
See EYE, DISORDERS OF.
Dartos
Dactinomycin The thin muscle just under the skin of the
A CYTOTOXIC antibiotic drug principally used SCROTUM which enables the scrotum to alter its
for treating cancers such as acute LEUKAEMIA shape.
and LYMPHOMA in children. It is given intra-
venously and treatment normally takes place in Databases
hospital. The drug was previously known as See HEALTH DATABASES.
actinomycin D. Side-effects are potentially
serious. Data Protection Act 1998
This legislation puts into effect the UK Euro-
Dactylitis pean Directive 95/46/EC on the processing of
Inflammation of a finger or toe. personal data, whether paper or computer
records. The Act is based on eight principles,
Danazol the first of which stipulates that personal data
This drug inhibits pituitary gonadotrophin shall be processed fairly and lawfully.
secretion (see PITUITARY GLAND; GONADO- Unfortunately this phrase is open to different
TROPHINS) and is used in the treatment of interpretations. Clarification is required to
ENDOMETRIOSIS, MENORRHAGIA and GYNAE- determine how the common-law duty of con-
COMASTIA. The dose is usually of the order of fidentiality affects the health services in the con-
100 mg twice daily and side-effects may include text of using data obtained from patients for
nausea, dizziness, flushing and skeletal muscle research work, especially epidemiological stud-
pain. It is mildly androgenic (see ANDROGEN). ies (see EPIDEMIOLOGY). Health authorities,
trusts and primary care groups in the NHS have
Dandruff appointed Caldicott guardians named after a
Also known as scurf. The white scales shed from review of information that identifies patients. A
the scalp, due to increased production of epi- prime responsibility of the guardians is to agree
dermal surface cells. Treatment is regular wash- and review internal protocols for the protection
ing with an antidandruff shampoo. (See also and use of identifiable information obtained
SEBORRHOEA.) from patients. The uncertainties over the inter-
pretation of the legislation require clarification,
Dangerous Drugs but some experts have suggested a workable
See CONTROLLED DRUGS. solution: to protect patients rights, researchers
should ensure that data are fully anonymised
Dantrolene whenever possible; they should also agree their
A muscle-relaxing drug, indicated for chronic project design with those responsible for data
severe spasticity (see SPASTIC) of voluntary protection well in advance of its planned start-
muscle such as may occur after a STROKE or in ing date. (See ETHICS.)
CEREBRAL PALSY and MULTIPLE SCLEROSIS (MS).
Unlike most other relaxants, it acts directly on Date Rape
the muscle, thus producing fewer central- See DRUG ASSISTED RAPE.
nervous-system side-effects. It is contraindi-
cated if liver function is impaired, and is not Day Blindness
recommended for children or for acute muscle A condition in which the patient sees better in a
 Dead, Disposal of the 181

dim light or by night than in daylight. It is only death, the captain may decide to preserve the
found in conditions in which the light is very body and refer the case to the relevant author-
glaring, as in the desert and on snow, and is ities at the next port of call.
relieved by resting the retina (see EYE) for
example, by wearing coloured glasses for a time. Embalming is still used occasionally. The
process consists in removing the internal organs
Daydreams through small openings, and filling the body
Daydreams occur when an individual during cavities with various aromatics of antiseptic D
waking hours imagines enjoyable or exciting power the skin being swathed in bandages or
events or images. Most people daydream at otherwise protected from the action of the air.
some stage during their lives, but it tends to Bodies are also preserved by injecting the blood
occur when someone is stressed or unhappy. vessels with strong antiseptics such as perchlo-
Children and teenagers in particular may some- ride of mercury.
times daydream a lot. This should not usually
worry their parents or teachers unless their Cremation or incineration of the body is
work suffers or it affects the individuals per- now the commonest method of disposal of the
sonal relationships. dead in the UK, where land for burials is
In those circumstances professional advice increasingly scarce; today it accounts for around
should be sought from a doctor or counsellor. 75 per cent of disposals. The process of inciner-
ation takes 12 hours. Something in the range
Day Surgery of 23 to 32 kg (57 lbs) of ash result from the
Surgery done in a clinic or a hospital without an combustion of the body, and there is no admix-
overnight stay either before or after the oper- ture with that from the fuel.
ation. Improvements in surgery especially the Cremation of a body means that it is almost
introduction of MINIMALLY INVASIVE SURGERY impossible to conduct any meaningful forensic
(MIS) as well as more effective methods of tests should any subsequent doubts be raised
ANAESTHESIA have simplified many procedures about the cause of death. So, before cremation
and reduced the physical and mental stress on can take place, two doctors have to sign the
patients. Patients undergoing day surgery cremation forms. The first is usually the doctor
should be accompanied home by a friend or who was caring for the patient at the time of
relative. Occasionally a patient may develop death an important exception being cases of
complications that require a post-operative stay sudden death, when the coroner holds an
in hospital. inquest into the cause and authorises the neces-
sary approval for cremation. In 1999, fewer
DDI than 3,500 deaths were certified following a
Also known as ddI see DIDANOSINE. post-mortem, out of a total number of deaths in
England and Wales of more than 556,000.
DDT When the coroner is not involved, the second
See DICHLORODIPHENYL TRICHLOROETHANE. doctor must have been qualified for five years;
he or she must be unconnected with the
Dead, Disposal of the patients care and not linked professionally with
Practically, only three methods have been used the first doctor. (For example, if the first doctor
from the earliest times: burial, embalming and is a general practitioner as in the majority of
cremation. Burial is perhaps the earliest and cases they are the second doctor should be
most primitive method. It was customary to from another practice.) Before signing the cre-
bury the bodies of the dead in consecrated mation certificate the second doctor must con-
ground around churches up until the earlier duct an external examination of the dead per-
half of the 19th century, when the utterly son and discuss the circumstances of death with
insanitary state of churchyards led to legislation the first doctor.
for their better control. Burials in Britain take The two cremation forms are then inspected
place usually upon production of a certificate by crematorium medical referees who must be
from a registrar of deaths, to whom notice of satisfied that the cause of death has definitely
the death, accompanied by a medical certificate, been ascertained. The present death and crema-
must be given without delay by the nearest tion certification system has been in place in the
relatives. UK for many years the legislative framework
When a death occurs at sea, the captain of for cremation was set up in 1902 and death
the ship has authority to permit burial at sea. If, certification procedures were last reviewed by
however, there are any doubts about cause of the government-appointed Brodrick committee
 182 Dead Fingers

in 1971, with no fundamental changes pro- chronic otitis media where there is inflamma-
posed. The case of Harold Shipman, a general tion of the middle ear, often with a perforation
practitioner convicted of murdering more than of the ear drum. It is thought that in the major-
15 patients, and suspected of murdering many ity of cases this is a sequela of childhood
more, has revealed serious weaknesses in the middle-ear disease. Many preschool children
certification system. A comprehensive review of suffer temporary hearing loss because of otitis
the present procedures was in place at the time media with effusion (glue ear). Wax does not
D of writing (2004). interfere with hearing unless it totally obstructs
the ear canal or is impacted against the tym-
Dead Fingers panic membrane. (See also EAR; EAR, DISEASES
See RAYNAUDS DISEASE. OF.)

Deadly Nightshade Treatment Conductive hearing impairment

The popular name of Atropa belladonna, from can, in many cases, be treated by an operation
which ATROPINE is procured. Its poisonous on the middle ear or by the use of a hearing aid.
black berries are sometimes eaten by children. Sensorineural hearing impairments can be
treated only with a hearing aid. In the UK,
Dead Space hearing aids are available free on the NHS.
Gas exchange only occurs in the terminal parts Most NHS hearing aids are ear-level hearing
of the pulmonary airways (see LUNGS). That aids that is, they fit behind the ear with the
portion of each breath that is taken into the sound transmitted to the ear via a mould in the
lungs but does not take part in gas exchange is external ear. Smaller hearing aids are available
known as dead space. Anatomical dead space which fit within the ear itself, and people can
describes air in the airways up to the terminal wear such aids in both ears. The use of certain
BRONCHIOLES. Physiological dead space also types of hearing aid may be augmented by fit-
includes gas in alveoli (air sacs) which are tings incorporated into the aid which pick up
unable to take part in gas exchange because of sound directly from television sets or from tele-
structural abnormalities or disease. phones, and from wire loop systems in halls,
lecture theatres and classrooms. More recently,
Deafness bone-anchored hearing aids have been
Impairment of hearing, which affects about 2 developed where the hearing aid is attached dir-
million adults in the UK. In infants, permanent ectly to the bones of the skull using a titanium
deafness is much less common: about 12 per screw. This type of hearing aid is particularly
1,000. It is essential, however, that deafness is useful in children with abnormal or absent ear
picked up early so that appropriate treatment canals who cannot therefore wear conventional
and support can be given to improve hearing hearing aids. People with hearing impairment
and/or ensure that the child can learn to speak. should seek audiological or medical advice
In most people, deafness is a result of sen- before purchasing any of the many types of
sorineural hearing impairment, commonly hearing aid available commercially. Those
known as nerve deafness. This means that the people with a hearing impairment which is so
abnormality is located in the inner ear (the profound (stone deaf) that they cannot be
cochlea), in the auditory nerve, or in the brain helped by a hearing aid can sometimes now be
itself. The prevalence of this type of hearing fitted with an electrical implant in their inner
impairment rises greatly in elderly people, to ear (a cochlear implant).
the extent that more than 50 per cent of the Congenital hearing loss accounts for a very
over-70s have a moderate hearing impairment. small proportion of the hearing-impaired
In most cases no definite cause can be found, population. It is important to detect at an
but contributory factors include excessive early stage as, if undetected and unaided, it
exposure to noise, either at work (e.g. shipyards may lead to delayed or absent development of
and steelworks) or at leisure (loud music). Any- speech. Otitis media with effusion (glue ear)
one who is exposed to gunfire or explosions is usually resolves spontaneously, although if it
also likely to develop some hearing impairment: persists, surgical intervention has been the
service personnel, for example. traditional treatment involving insertion of a
Conductive hearing impairment is the other ventilation tube (see GROMMET) into the ear
main classification. Here there is an abnormal- drum, often combined with removal of the
ity of the external or middle ear, preventing the adenoids (see NOSE, DISORDERS OF). Recent
normal transmission of sound waves to the studies, however, suggest that in many chil-
inner ear. This is most commonly due to dren these operations may provide only transi-
 Death, Signs of 183

ent relief and make no difference to long-term of the facial muscles (which produces the star-
outcome. ing eye and gaping mouth of the Hippocratic
Advice and information on deafness and countenance), as well as a loss of the curves of
hearing aids may be obtained from the Royal the back, which becomes flat by contact with
National Institute for Deaf People and other the bed or table; discoloration of the skin,
organisations. which takes on a wax-yellow hue and loses its
pink transparency at the finger-webs; absence of
Deamination blistering and redness if the skin is burned D
The process of removal of the amino group, (Christisons sign); and failure of a ligature tied
NH2, from amino acids not required for build- round the finger to produce, after its removal,
ing up body PROTEIN. This is carried out the usual change of a white ring, which, after a
mainly in the liver by means of an enzyme, few seconds, becomes redder than the sur-
deaminase. The fatty acid residue is either rounding skin in a living person.
burnt up to yield energy, or is converted into The only certain sign of death, however, is
glucose. that the heart has stopped beating. To ensure
that this is permanent, it is necessary to listen
Death, Causes of over the heart with a stethoscope, or directly
The final cause of death is usually the failure of with the ear, for at least five minutes. Perman-
the vital centres in the brain that control the ent stoppage of breathing should also be con-
beating of the heart and the act of breathing. firmed by observing that a mirror held before
The important practical question, however, is the mouth shows no haze, or that a feather
what disease, injury or other agent has led to placed on the upper lip does not flutter.
this failure. Sometimes the cause may be obvi- In the vast majority of cases there is no dif-
ous for example, pneumonia, coronary ficulty in ensuring that death has occurred. The
thrombosis, or brain damage in a road accident. introduction of organ transplantation, however,
Often, however, the cause can be uncertain, in and of more effective mechanical means of
which case a POST-MORTEM EXAMINATION is resuscitation, such as ventilators, whereby an
necessary. individuals heart can be kept beating almost
The two most common causes of death in the indefinitely, has raised difficulties in a minority
UK are diseases of the circulatory system of cases. To solve the problem in these cases the
(including strokes and heart disease) and cancer. concept of brain death has been introduced. In
Overall annual death rates among women in this context it has to be borne in mind that
the UK at the start of the 21st century were there is no legal definition of death. Death has
7.98 per 1,000 population, and among men, traditionally been diagnosed by the irreversible
5.58 per 1,000. Comparable figures at the start cessation of respiration and heartbeat. In the
of the 20th century were 16.3 for women and Code of Practice drawn up in 1983 by a Work-
18.4 for men. The death rates in 1900 among ing Party of the Health Departments of Great
infants up to the age of four were 47.9 per Britain and Northern Ireland, however, it is
1,000 females and 57 per 1,000 males. By 2003 stated that death can also be diagnosed by the
these numbers had fallen to 5.0 and 5.8 respect- irreversible cessation of brain-stem function.
ively. All these figures give a crude indication of This is described as brain death. The brain
how the health of Britains population has stem consists of the mid-brain, pons and
improved in the past century. medulla oblongata which contain the centres
Death rates and figures on the causes of controlling the vital processes of the body such
deaths are essential statistics in the study of EPI- as consciousness, breathing and the beating of
DEMIOLOGY which, along with information on the heart (see BRAIN). This new concept of
the incidence of illnesses and injuries, provides death, which has been widely accepted in med-
a temporal and geographical map of changing ical and legal circles throughout the world,
health patterns in communities. Such informa- means that it is now legitimate to equate brain
tion is valuable in planning preventive health death with death; that the essential component
measures (see PUBLIC HEALTH) and in identify- of brain death is death of the brain stem; and
ing the natural history of diseases knowledge that a dead brain stem can be reliably diagnosed
that often contributes to the development of at the bedside. (See GLASGOW COMA SCALE.)
preventive measures and treatments for those Four points are important in determining the
diseases. time that has elapsed since death. HYPOSTASIS,
or congestion, begins to appear as livid spots on
Death, Signs of the back, often mistaken for bruises, three
There are some minor signs, such as: relaxation hours or more after death. This is due to the
 184 Death, Sudden

blood running into the vessels in the lowest whom 9 million were over 65 and 4.2 million
parts. Loss of heat begins at once after death, over 75. Females comprised 30.33 million and
and the body has become as cold as the sur- males 29.47. In 2003 the latest year for which
rounding air after 12 hours although this is figures are available the death rate was 7.2
delayed by hot weather, death from ASPHYXIA, per 1,000 population; in 1980 the figure was
and some other causes. Rigidity, or rigor mortis, 11.8. The total mortality comprises individual
begins in six hours, takes another six to become deaths from different causes: for example, acci-
D fully established, remains for 12 hours and dents, cancer, coronary artery disease, strokes
passes off during the succeeding 12 hours. It and suicides. Mortality is often calculated for
comes on quickly when extreme exertion has specific groups in epidemiological (see EPI-
been indulged in immediately before death; DEMIOLOGY) studies of particular diseases.
conversely it is slow in onset and slight in death Infant mortality measures the deaths of babies
from wasting diseases, and slight or absent in born alive who die during the first year of life:
children. It begins in the small muscles of the infant deaths per 1,000 live births were steady
eyelid and jaw and then spreads over the body. at around 5 from 20032005.
PUTREFACTION is variable in time of onset, but
usually begins in 23 days, as a greenish tint Debility
over the abdomen. A state of weakness.

Death, Sudden Debridement

If deaths from accidents are excluded, this term The surgical removal of foreign material and
means the unexpected death of an apparently damaged tissue from a wound.
healthy person. CARDIAC ARREST is the most
common cause of sudden death. Older people Decay, Dental
(35 years or above) who suffer cardiac arrest See TEETH, DISORDERS OF Caries of the teeth.
commonly have coronary artery disease (see
HEART, DISEASES OF) with restriction or stop- Decibel
page of blood supply to part of the heart which The unit of hearing. One decibel is the least
causes INFARCTION (heart attack). Irregularity intensity of sound at which a given note can be
of the heartbeat (cardiac ARRHYTHMIA) is heard. The usual abbreviation for decibel is dB.
another cause. MYOCARDITIS, PNEUMONIA and
STROKE can also result in sudden death, as can Decidua
ASTHMA, anaphylactic shock (see ANAPHYLAXIS), The soft coat which lines the interior of the
ruptured aortic ANEURYSM and SUICIDE, the womb during pregnancy and which is cast off at
incidence of which is rising, especially among birth.
young people, and is over 4,000 a year in the
UK. Decoction
Sudden death sometimes occurs in infants, A preparation made by boiling various plants in
usually in the first year of life: this is called water and straining the fluid.
SUDDEN INFANT DEATH SYNDROME (SIDS) or,
colloquially, cot death, the possible causes of Decompensation
which are an ongoing subject for research and A failing condition of the heart in a case of
debate. valvular disease (see HEART, DISEASES OF).
When a person dies unexpectedly the event
must be reported to a CORONER, who has the Decongestants
power to decide whether an AUTOPSY is Drugs which relieve nasal congestion and
necessary. stuffiness. They may be given orally or by nasal
spray, and most are SYMPATHOMIMETIC DRUGS
Death Certificate which cause vasoconstriction in the nasal
A certificate required by law to be signed by a mucosa. Too frequent use reduces their
medical practitioner stating the main and any effectiveness, and there is a danger of rebound
contributary causes of a persons death. worsening if they are used for more than 1014
days. A safer option for babies is simple sodium
Death Rate chloride drops. Warm moist air is also a trad-
The death (mortality rate) is the number of itional effective decongestant.
deaths per 100,000 or sometimes 10,000 or
1,000 of the population per year. In 2001 the Decubitus
population of the UK was 59.8 million, of Decubitus refers to the positions taken up in
 Dehydration 185

bed by patients suffering from various condi- SCALDS; CHEST, DEFORMITIES OF; TALIPES;
tions such as pneumonia, PERITONITIS, or FLAT-FOOT; JOINTS, DISEASES OF; KNOCK-KNEE;
severe exhaustion. Such patients are liable to LEPROSY; PALATE, MALFORMATIONS OF; PAR-
develop bed sores, or decubitus ulcer (see ALYSIS; RICKETS; SCAR; SKULL; SPINE AND
ULCER). SPINAL CORD, DISEASES AND INJURIES OF.)

Decussation Degeneration
Any point in the nervous system at which nerve A change in structure or in chemical com- D
fibres cross from one side to the other: for position of a tissue or organ, by which its vital-
example, the decussation of the pyramidal ity is lowered or its function interfered with.
tracts in the medulla (see BRAIN), where the Degeneration is of various kinds, the chief
motor fibres from one side of the brain cross to being fatty, where cells become invaded by fat
the other side of the spinal cord. globules; calcareous, where calcium is deposited
in tissue so that it becomes chalky in
Deep Vein Thrombosis (DVT) consistency; and mucoid, where it becomes
See THROMBOSIS; VEINS, DISEASES OF. semi-liquefied.
Causes of degeneration are, in many cases,
Defaecation very obscure. In some cases heredity plays a
Opening the bowels. (See CONSTIPATION; part, with particular organs for example, the
DIARRHOEA.) kidneys tending to show fibroid changes in
successive generations. Fatty, fibroid, and cal-
Defibrillation careous degenerations are part of the natural
If a heart is fibrillating (see VENTRICULAR FIB- change in old age; defective nutrition may bring
RILLATION), the application of a large electric them on prematurely, as may excessive and
shock via paddles applied to the chest wall long-continued strain upon an organ like the
causes simultaneous electrical depolarisation of heart. Various poisons, such as alcohol, play a
all the cardiac cells, and may allow the hearts special part in producing the changes, and so
natural pacemaker to re-establish sinus rhythm. do the poisons produced by various diseases,
One paddle is placed below the right clavicle particularly SYPHILIS and TUBERCULOSIS.
and the other over the cardiac apex. Care must
be taken that no one is in contact with the Degenerative Disorders
patient or the bed when the shock is given, to An umbrella description for a wide variety of
avoid electrocution. conditions in which there is increased deterior-
ation of the structure or function (or both) of
Defibrillator the body. Ageing causes a steady degeneration
Apparatus that delivers a controlled electric of many tissues and organs for example,
shock to restore normal heart rhythm in wrinkling of the skin, CATARACT and poor
patients whose hearts have developed VEN- neuromuscular coordination. In degenerative
TRICULAR FIBRILLATION or have stopped beat- disorders the changes occur earlier in life. The
ing. The shock is delivered by electrodes placed nervous system, muscles, arteries, joints and
on the chest wall or directly to the heart after eyes are all susceptible. Specialised tissues are
the chest has been surgically opened. Defibrilla- replaced by CONNECTIVE TISSUE. The com-
tors are a standard item of equipment for para- monest example in the nervous system is
medical staff in ambulances, and aeroplanes of ALZHEIMERS DISEASE, which causes dementia;
some airlines now routinely carry the apparatus. while in HUNTINGTONS CHOREA, a genetic
(See also HEART, DISEASES OF.) disorder, dementia is accompanied by
incoordination of movements.
Deficiency Disease
Any disease resulting from the absence from the Deglutition
diet of any substance essential to good health: Deglutition means the act of swallowing. (See
for example, one of the vitamins. CHOKING.)

Deformities Dehiscence
Malformations or distortions of part of the The breaking open of a wound that is partly
body. They may be present at birth, or they may healed, usually after surgery.
be the result of injuries, or disease, or simply
produced by bad posture, like the curved spine Dehydration
occasionally found in children. (See BURNS AND A fall in the water content of the body. Sixty per
 186 Dj Vu

cent of a mans body weight is water, and 50 Delhi Boil

per cent of a womans; those proportions need Delhi boil is a form of chronic body sore
to be maintained within quite narrow limits to occurring in Eastern countries, caused by a
ensure proper functioning of body tissues. protozoan parasite, Leishmania tropica. (See
Body fluids contain a variety of mineral salts LEISHMANIASIS.)
(see ELECTROLYTES) and these, too, must
remain within narrow concentration bands. Delinquency
D Dehydration is often accompanied by loss of Behaviour by a young person that would be
salt, one of the most important minerals in the judged a crime if carried out by an adult.
body. Delinquency may also include non-criminal
The start of dehydration is signalled by a activities for example, running away from
person becoming thirsty. In normal circum- home, missing school lessons, drug or alcohol
stances, the drinking of water will relieve thirst abuse, and unruly behaviour in public places.
and serious dehydration does not develop. In a Delinquency is now a serious social problem in
temperate climate an adult will lose 1.5 litres or the UK, especially in deprived areas, and it is
more a day from sweating, urine excretion and increasingly accompanied by alcohol and drug
loss of fluid through the lungs. In a hot climate abuse.
the loss is much higher up to 10 litres if a
person is doing hard physical work. Even in a Delirium
temperate climate, severe dehydration will A condition of altered consciousness in which
occur if a person does not drink for two or three there is disorientation (as in a confusional
days. Large losses of fluid occur with certain state), incoherent talk and restlessness but
illnesses for example, profuse diarrhoea; with hallucination, illusions or delusions also
POLYURIA in diabetes or kidney failure (see present.
KIDNEYS, DISEASES OF); and serious blood loss
from, say, injury or a badly bleeding ULCER in Delirium (confusion) In some old people,
the gastrointestinal tract. Severe thirst, dry lips acute confusion is a common effect of physical
and tongue, TACHYCARDIA, fast breathing, illness. Elderly people are often referred to as
lightheadedness and confusion are indicative of being confused; unfortunately this term is
serious dehydration; the individual can lapse often inappropriately applied to a wide range of
into COMA and eventually die if untreated. eccentricities of speech and behaviour as if it
Dehydration also results in a reduction in out- were a diagnosis. It can be applied to a patient
put of urine, which becomes dark and with the early memory loss of DEMENTIA for-
concentrated. getful, disorientated and wandering; to the
Prevention is important, especially in hot dejected old person with depression, often
climates, where it is essential to drink water termed pseudo-dementia; to the patient whose
even if one is not thirsty. Replacement of salts is consciousness is clouded in the delirium of
also vital, and a diet containing half a teaspoon acute illness; to the paranoid deluded sufferer
of table salt to every litre of water drunk is of late-onset SCHIZOPHRENIA; or even to the
advisable. If someone, particularly a child, suf- patient presenting with the acute DYSPHASIA
fers from persistent vomiting and diarrhoea, and incoherence of a stroke. Drug therapy may
rehydration therapy is required and a salt-and- be a cause, especially in the elderly.
glucose rehydration mixture (obtainable from
pharmacists) should be taken. For those with Delirium tremens is the form of delirium
severe dehydration, oral fluids will be insuffi- most commonly due to withdrawal from alco-
cient and the affected person needs intravenous hol, if a person is dependent on it (see DEPEND-
fluids and, sometimes, admission to hospital, ENCE). There is restlessness, fear or even terror
where fluid intake and output can be moni- accompanied by vivid, usually visual, hallucin-
tored and rehydration measures safely ations or illusions. The level of consciousness is
controlled. impaired and the patient may be disorientated
as regards time, place and person.
Dj Vu Treatment is, as a rule, the treatment of
A feeling of having already experienced an causes. (See also ALCOHOL.) As the delirium in
event which the person is doing or seeing at fevers is due partly to high temperature, this
the moment. French for already seen, dj vu should be lowered by tepid sponging. Careful
is quite common but no satisfactory explan- nursing is one of the keystones of successful
ation for the phenomenon has yet been treatment, which includes ensuring that ample
discovered. fluids are taken and nutrition is maintained.
 Dengue 187

Delivery and incoherent speech commonly develop.

The final expulsion of the child in the act of Similar symptoms to those in dementia can
birth. (See PREGNANCY AND LABOUR.) occur in curable conditions including depres-
sion, INTRACRANIAL tumours, SUBDURAL
Delta Waves haematoma, SYPHILIS, vitamin B1 deficiency (see
Abnormal electrical waves observed in the elec- APPENDIX 5: VITAMINS) and repeated episodes of
troencephalogram (see ELECTROENCEPHAL- cerebral ISCHAEMIA. This last may lead to
OGRAPHY (EEG)). The frequency of the normal multi-infarct dementia. D
alpha waves is 10 per second; that of the delta
waves is 7 or fewer per second. They occur in Treatment If organic disease is identified, it
the region of tumours of the brain, and in the should, where possible, be treated; otherwise
brains of patients with EPILEPSY. the treatment of dementia is alleviation of its
symptoms. The affected person must be kept
Deltoid clean and properly fed. Good nursing care in
The powerful triangular muscle attached above comfortable surroundings is important and
to the collar-bone and shoulder-blade, and sedation with appropriate drugs may be
below, by its point, to the humerus, nearly half- required. Patients may eventually need insti-
way down the outer side of the upper arm. Its tutional care. (See ALZHEIMERS DISEASE.)
action is to raise the arm from the side, and it
covers and gives roundness to the shoulder. (See Demography
also MUSCLE.) The study of populations and factors affecting
their health.
Delusions
An irrational and usually unshakeable belief De Morgans Spots
(ide fixe) peculiar to some individuals. They De Morgans spots are a type of small HAE-
fail to respond to reasonable argument and the MANGIOMA occuring in the skin of middle-aged
delusion is often paranoid in character with a people. No more than 3 mm in diameter, they
belief that a person or persons is/are persecuting are rarely widespread and are not malignant.
them. The existence of a delusion, of such a
nature as to influence conduct seriously, is one Demyelination
of the most important signs in reaching a deci- Destruction of the fatty MYELIN sheath around
sion to arrange for the compulsory admission of nerve fibres (see NERVE: NEURON(E)) which
the patient to hospital for observation. (See interferes with the nerve function. It can occur
MENTAL ILLNESS.) after injury to the nerve, but is particularly
associated with MULTIPLE SCLEROSIS (MS).
Dementia
An acquired and irreversible deterioration in Dendritic Ulcer
intellectual function. Around 10 per cent of A branching ULCER on the surface of the cornea
people aged over 65 and 20 per cent of those of the eye, caused by HERPES SIMPLEX infection.
aged 75 or over are affected to some extent. The
disorder is due to progressive brain disease. It Denervation
appears gradually as a disturbance in problem- Interruption of the nerve supply to an organ or
solving and agility of thought which may be other structure.
considered to be due to tiredness, boredom or
DEPRESSION. As memory failure develops, the Dengue
affected person becomes bewildered, anxious Also known as dengue fever, breakbone fever,
and emotional when dealing with new sur- and dandy fever, dengue is endemic and epi-
roundings and complex conversations. In pro- demic in tropical and subtropical regions. It is
fessional skilled workers this is frequently first an acute infection caused by a flavivirus (family
recognised by family and friends. Catastrophic togaviridae) transmitted by mosquitoes espe-
reactions are usually brief but are commonly cially Aedes aegypti. Incubation period is 58
associated with an underlying depression which days, and is followed by abrupt onset of symp-
can be mistaken for progressive apathy. The toms: fever, facial ERYTHEMA with intense itch-
condition progresses relentlessly with loss of ing (which spreads throughout the body), sore
recent memory extending to affect distant throat, running eyes, and painful muscles and
memory and failure to recognise even friends joints are common accompaniments. The
and family. Physical aggression, unsocial symptoms subside within a few days and are
behaviour, deteriorating personal cleanliness frequently succeeded by a relapse similar to the
 188 Dental Emergencies

first. Further relapses may occur, and joint pains aware that oral disorders may reflect disease
continue for some months. In uncomplicated elsewhere in the body. They will refer to the
dengue the mortality rate is virtually zero. hospital dental services, patients who require
Diagnosis is by virus isolation or demonstration treatment that cannot be satisfactorily carried
of a rising antibody-concentration in the acute out in a primary-care setting.
phase of infection. There is no specific treat- Most routine dental prevention and
ment, but mild analgesics can be used to relieve treatment is carried out in general dental
D the pains, and calamine lotion the itching. Pre- practitioners surgeries, where the dentists also
vention can be achieved by reduction of the supervise the work of hygienists and dental
mosquito-vector population. auxiliaries. Appliances, such as dentures,
crowns, bridges and orthodontic appliances are
Dengue haemorrhagic fever This is a constructed by dental technicians working in
more severe form of the disease which usually dental laboratories.
occurs in young children; it is largely confined There are around 18,800 dentists providing
to the indigenous population(s) of south-east general dental services in the UK. These practi-
Asia. It is accompanied by significant complica- tioners are free to accept or reject any potential
tions and mortality. Immunological status of the patient and to practise where they wish. Those
host is considered important in pathogenesis. dentists treating patients under an NHS con-
tract (a mixture of capitation fees and items of
Dental Emergencies service payments) can also treat patients pri-
See TEETH, DISORDERS OF. vately (for an appropriate fee). Some dentists
opt for full-time private practice, and their
Dental Hygienist numbers are increasing in the wake of changes
A person qualified to carry out the scaling in 1990 in the contracts of NHS general dental
(removal of calculus [deposits]) from the teeth practitioners.
and to advise patients on how to keep their
teeth and gums healthy. Hygienists usually Community dental practitioner Part of
work in a qualified dentists surgery. the public-health team and largely concerned
with monitoring dental health and treating the
Dental Surgeon young and the handicapped.
A dental surgeon, or dentist, is an individual In the hospitals and dental schools are those
trained to diagnose and treat disorders of the who are involved in only one of the specialities.
teeth and gums, as well as to advise on prevent- Around 2,800 dentists work in NHS hos-
ive measures to ensure that these areas remain pitals and 1,900 in the NHSs community ser-
healthy. Dentists qualify after a four-year course vices. In some parts of the UK, people wanting
at dental school and then register with the GEN- NHS treatment are having difficulties finding
ERAL DENTAL COUNCIL, which is responsible dentists willing to provide such care.
for maintaining educational and professional
standards. Around 25,000 dentists practise in Restorative dentist Concerned with the
the NHS and private sector. repair of teeth damaged by trauma and caries,
Over the past four decades the financial out- and the replacement of missing teeth.
lay on NHS dental services has been around 5
Orthodontist Correction of jaws and teeth
per cent of total NHS funding. This contrasts
which are misaligned or irregular. This is done
with 10 per cent during the services early years,
with appliances which may be removable or
when the NHS was coping with decades of
fixed to the teeth which are then moved with
dental neglect. The populations dental health
springs or elastics.
has, however, been steadily improving: in 1968
more than one-third of people had no natural Oral and maxillo-facial surgeons
teeth; by the late 1990s the proportion had Perform surgery to the mouth and face. This
fallen to 13 per cent. not only includes removal of buried teeth but
Dentistry is divided into several groupings. also treatment for fractured facial bones,
removal of cancers and the repair of missing
General dental practitioners Con- tissue, and the cosmetic restoration of facial
cerned with primary dental care, the preven- anomalies such as CLEFT PALATE or large or
tion, diagnosis and treatment of diseases of the small jaws.
gums and teeth for example, caries (see TEETH,
DISORDERS OF). They also deal with difficulties Dentine
in biting and the effects of trauma, and are See TEETH.
 Dependence 189

Dentist drug to avoid distressing withdrawal or abstin-

See DENTAL SURGEON. ence symptoms. Thus, determinants and the
problematic consequences of drug dependence
Dentition may be biological, psychological or social and
See TEETH. usually interact.
Different drugs cause different rates of
Denture dependence: TOBACCO is the most common
A plate or frame bearing false teeth. It may be substance of addiction; HEROIN and COCAINE D
complete (replacing all the teeth in one jaw) or cause high rates of addiction; whereas ALCOHOL
partial. is much lower, and CANNABIS lower again.
Smoking in the western world reached a peak
Deodorants after World War II with almost 80 per cent of
Substances which remove or lessen objection- the male population smoking. The reports on
able odours. Some, which have a powerful the link between smoking and cancer in the
odour, simply cover other smells, but the most early 1960s resulted in a decline that has con-
effective act by giving off oxygen, so as to con- tinued so that only around a quarter of the
vert the objectionable substances into simple adult populations of the UK and USA smokes.
and harmless ones. Globally, tobacco consumption continues to
grow, particularly in the developing world with
Varieties Volatile oils of plants, such as euca- multinational tobacco companies marketing
lyptus and turpentine, chlorine water and chlor- their products aggressively.
inated lime, peroxide of hydrogen and charcoal Accurate figures for illegal drug-taking are
have been used as deodorants. There are now hard to obtain, but probably approximately 4
many commercial products available. per cent of the population is dependent on
alcohol and 2 per cent on other drugs, both
Deoxyribonucleic Acid legal and illegal, at any one time in western
See DNA. countries.

Dependence How does dependence occur? More

Physical or psychological reliance on a sub- than 40 distinct theories or models of drug
stance or an individual. A baby is naturally misuse have been put forward. One is that the
dependent on its parents, but as the child individual consumes drugs to cope with per-
develops, this dependence lessens. Some adults, sonal problems or difficulties in relations with
however, remain partly dependent, making others. The other main model emphasises
abnormal demands for admiration, love and environmental influences such as drug avail-
help from parents, relatives and others. ability, environmental pressures to consume
The dependence that most concerns modern drugs, and sociocultural influences such as peer
society is one in which individuals become pressure.
dependent on or addicted to certain substances By contrast to these models of why people
such as alcohol, drugs, tobacco (nicotine), caf- misuse drugs, models of compulsive drug use
feine and solvents. This is often called sub- where individuals have a compulsive addiction
stance abuse. Some people become addicted to have been amenable to testing in the labora-
certain foods or activities: examples of the latter tory. Studies at cellular and nerve-receptor
include gambling, computer games and use of levels are attempting to identify mechanisms of
the Internet. tolerance and dependence for several sub-
The 28th report of the World Health Organ- stances. Classical behaviour theory is a key
isation Expert Committee on Drug Depend- model for understanding drug dependence.
ence in 1993 defined drug dependence as: A This and current laboratory studies are being
cluster of physiological, behavioural and cogni- used to explain the reinforcing nature of
tive phenomena of variable intensity, in which dependent substances and are helping to pro-
the use of a psychoactive drug (or drugs) takes vide an explanatory framework for dependence.
on a high priority. The necessary descriptive Drug consumption is a learned form of
characteristics are preoccupation with a desire behaviour. Numerous investigators have used
to obtain and take the drug and persistent drug- conditioning theories to study why people mis-
seeking behaviour. Psychological dependence use drugs. Laboratory studies are now locating
occurs when the substance abuser craves the the reward pathways in the brain for opiates
drugs desirable effects. Physical dependence and stimulants where positive reinforcing
occurs when the user has to continue taking the mechanisms involve particular sectors of the
 190 Depigmentation

brain. There is a consensus among experts in central nervous system, making the user feel
addiction that addictive behaviour is amenable confident, energetic, and powerful for several
to effective treatment, and that the extent to hours. They can also cause severe insomnia,
which an addict complies with treatment makes anxiety, paranoia, psychosis, and even sudden
it possible to predict a positive outcome. But death due to convulsions or tachycardia.
there is a long way to go before the mechanisms Depression may occur on withdrawal of these
of drug addiction are properly understood or drugs, and in some users this is sufficiently
D ways of treating it generally agreed. deterrent to cause psychological dependence.
Amphetamine (speed) is mainly synthesised
Effects of drugs Cannabis, derived from illegally and may be eaten, sniffed, or injected.
the plant Cannabis sativa, is a widely used recre- Related drugs, such as dexamphetamine sul-
ational drug. Its two main forms are marijuana, phate (Dexedrine), are prescribed pills that
which comes from the dried leaves, and hashish enter the black market. ECSTASY is another
which comes from the resin. Cannabis may be amphetamine derivative that has become a
used in food and drink but is usually smoked in popular recreational drug; it may have fatal
cigarettes to induce relaxation and a feeling of allergic effects. Cocaine and related drugs are
well-being. Heavy use can cause apathy and used in medicine as local anaesthetics. Illegal
vagueness and may even cause psychosis. supplies of cocaine (snow or ice) and its
Whether or not cannabis leads people to using derivative, crack, come mainly from South
harder drugs is arguable, and a national debate America, where they are made from the plant
is underway on whether its use should be legal- Erythroxylon coca. Cocaine is usually sniffed
ised for medicinal use. Cannabis may alleviate (snorted) or rubbed into the gums; crack is
the symptoms of some disorders for example, burnt and inhaled.
MULTIPLE SCLEROSIS (MS) and there are calls Opiate drugs are derived from the opium
to allow the substance to be classified as a pre- poppy, Papaver somniferum. They are described
scribable drug. as narcotic because they induce sleep. Their
About one in ten of Britains teenagers mis- main medical use is as potent oral or injectable
uses volatile substances such as toluene at some analgesics such as MORPHINE, DIAMORPHINE,
time, but only about one in 40 does so regularly. PETHIDINE HYDROCHLORIDE, and CODEINE.
These substances are given off by certain glues, The commonest illegal opiate is heroin, a pow-
solvents, varnishes, and liquid fuels, all of which dered form of diamorphine that may be
can be bought cheaply in shops, although their smoked, sniffed, or injected to induce euphoria
sale to children under 16 is illegal. They are and drowsiness. Regular opiate misuse leads to
often inhaled from plastic bags held over the tolerance (the need to take ever larger doses to
nose and mouth. Central-nervous-system exci- achieve the same effect) and marked depend-
tation, with euphoria and disinhibition, is fol- ence. A less addictive oral opiate, METHADONE
lowed by depression and lethargy. Unpleasant HYDROCHLORIDE, can be prescribed as a substi-
effects include facial rash, nausea and vomiting, tute that is easier to withdraw.
tremor, dizziness, and clumsiness. Death from Some 75,000150,000 Britons now misuse
COMA and acute cardiac toxicity is a serious risk. opiates and other drugs intravenously, and pose
Chronic heavy use can cause peripheral neur- a huge public-health problem because injec-
opathy and irreversible cerebellar damage. (See tions with shared dirty needles can carry the
SOLVENT ABUSE (MISUSE).) blood-borne viruses that cause AIDS/HIV and
The hallucinogenic or psychedelic drugs HEPATITIS B. Many clinics now operate schemes
include LYSERGIC ACID DIETHYLAMIDE (LSD) or to exchange old needles for clean ones, free of
acid, magic mushrooms, ecstasy (MDMA), and charge. Many addicts are often socially
phencyclidine (PCP or angel dust, mainly disruptive.
used in the USA). These drugs have no medi- For help and advice see APPENDIX 2:
cinal uses. Taken by mouth, they produce vivid ADDRESSES: SOURCES OF INFORMATION,
trips, with heightened emotions and percep- ADVICE, SUPPORT AND SELF-HELP National
tions and sometimes with hallucinations. They Dugs Helpline.
are not physically addictive but can cause (See ALCOHOL and TOBACCO for detailed
nightmarish bad trips during use and flashbacks entries on those subjects.)
(vivid reruns of trips) after use, and can prob-
ably trigger psychosis and even death, especially Depigmentation
if drugs are mixed or taken with alcohol. Also called hypo-pigmentation, this congenital
Stimulant drugs such as amphetamine and or acquired disorder is one in which the skin
cocaine act like adrenaline and speed up the loses its pigmentation because of reduced
 Depression 191

MELANIN production. It can be classified into Symptoms These vary with the illnesss sever-
three groups: VITILIGO, ALBINISM and post- ity. Anxiety and variable moods are the main
inflammatory hypopigmentation. symptoms in mild depression. The sufferer may
cry without any reason or be unresponsive to
Depilation relatives and friends. In its more severe form,
The process of destroying hair substances and depression presents with a loss of appetite,
processes used for this purpose being known as sleeping problems, lack of interest in and
depilatories. The purpose may be effected in enjoyment of social activities, tiredness for no D
three ways: by removing the hairs at the level of obvious reason, an indifference to sexual activ-
the skin surface; by pulling the hairs out (epil- ity and a lack of concentration. The individuals
ation); and by destroying the roots and so pre- physical and mental activities slow down and he
venting the growth of new hairs. or she may contemplate suicide. Symptoms
Shaving is the most effective way of remov- may vary during the 24 hours, being less
ing superfluous hairs. Rubbing morning and troublesome during the latter part of the day
night with a smooth pumice-stone is said to be and worse at night. Some people get depressed
helpful. Electrolysis and diathermy are also during the winter months, probably a con-
used. sequence of the long hours of darkness: this dis-
order SEASONAL AFFECTIVE DISORDER SYN-
Depression DROME, or SADS is thought to be more
Depression is a word that is regularly misused. common in populations living in areas with
Most people experience days or weeks when long winters and limited daylight. Untreated, a
they feel low and fed up (feelings that may person with depressive symptoms may steadily
recur), but generally they get over it without worsen, even withdrawing to bed for much of
needing to seek medical help. This is not clinical the time, and allowing his or her personal
depression, best defined as a collection of psy- appearance, hygiene and environment to
chological symptoms including sadness; deteriorate. Children and adolescents may also
unhappy thoughts characterised by worry, poor suffer from depression and the disorder is not
self-image, self-blame, guilt and low self- always recognised.
confidence; downbeat views on the future; and a
feeling of hopelessness. Sufferers may consider Causes A real depressive illness rarely has a
suicide, and in severe depression may soon single obvious cause, although sometimes the
develop HALLUCINATIONS and DELUSIONS. death of a close relative, loss of employment or
Doctors make the diagnosis of depression a broken personal relationship may trigger a
when they believe a patient to be ill with the bout. Depression probably has a genetic back-
latter condition, which may affect physical ground; for instance, manic depression seems
health and in some instances be life- to run in some families. Viral infections some-
threatening. This form of depression is com- times cause depression, and hormonal dis-
mon, with up to 15 per cent of the population orders for example, HYPOTHYROIDISM or
suffering from it at any one time, while about postnatal hormonal disturbances (postnatal
20 per cent of adults have medical depression depression) will cause it. Difficult family or
at some time during their lives such that it is social relations can contribute to the develop-
one of the most commonly presenting disorders ment of the disorder. Depression is believed to
in general practice. Women seem more liable to occur because of chemical changes in the
develop depression than men, with one in six of transmission of signals in the nervous system,
the former and one in nine of the latter seeking with a reduction in the neurochemicals that
medical help. facilitate the passage of messages throughout
Manic depression is a serious form of the the system.
disorder that recurs throughout life and is
manifested by bouts of abnormal elation the Treatment This depends on the type and
manic stage. Both the manic and depressive severity of the depression. These are three main
phases are commonly accompanied by psych- forms.
otic symptoms such as delusions, hallucinations PSYCHOTHERAPY either on a one-to-one basis
and a loss of sense of reality. This combination or as part of a group: this is valuable for those
is sometimes termed a manic-depressive psych- whose depression is the result of lifestyle or per-
osis or bipolar affective disorder because of the sonality problems. Various types of psycho-
illnesss division into two parts. Another psy- therapy are available.
chiatric description is the catch-all term affect- DRUG TREATMENT is the most common
ive disorder. method and is particularly helpful for those
 192 Depressor

with physical symptoms. ANTIDEPRESSANT diet and warmth. It was devised in the 1980s to
DRUGS are divided into three main groups: TRI- help assess the medical services needed by a
CYCLIC ANTIDEPRESSANT DRUGS (amitriptyl- socially deprived population.
ine, imipramine and dothiepin are examples);
MONOAMINE OXIDASE INHIBITORS (MAOIS) Dermabrasion
(phenelzine, isocarboxazid and tranylcy- Dermabrasion, or skin planing, is a method
promine are examples); and SELECTIVE SERO- of removing the superficial layers of the skin,
TONIN REUPTAKE INHIBITORS (SSRIS) (fluoxet- useful in the treatment of tattoos and acne
D
ine well known as Prozac, fluvoxamine and scars.
paroxetine are examples). For manic depression,
lithium carbonate is the main preventive drug Dermatitis
and it is also used for persistent depression that Synonymous with eczema in all respects.
fails to respond to other treatments. Long-term Although the lay term eczema usually refers to
lithium treatment reduces the likelihood of atopic (see ATOPY) or endogenous eczema, there
relapse in about 80 per cent of manic depres- are many other causes. Susceptibility to derma-
sives, but the margin between control and toxic titis is genetically determined in some cases; in
side-effects is narrow, so the drug must be care- others, environmental irritants and allergens are
fully supervised. Indeed, all drug treatment for implicated. Symptoms typically include itch-
depression needs regular monitoring as the sub- ing, dryness or cracking and, occasionally, sore-
stances have powerful chemical properties with ness of the skin. Physical signs include redness
consequential side-effects in some people. Fur- (erythema), scaling, and vesiculation (tiny blis-
thermore, the nature of the illness means that ters just beneath the surface of the skin). (See also
some sufferers forget or do not want to take the SKIN, DISEASES OF.)
medication.
ELECTROCONVULSIVE THERAPY (ECT) If drug
Dermatofibroma
treatments fail, severely depressed patients may Also known as histiocytoma. A firm, painless
be considered for ECT. This treatment has been nodule in the skin, typically on a leg, due to
used for many years but is now only rarely excessive formation of COLLAGEN. A common
recommended. Given under general anaes- disorder, it is often a slow response to an insect
thetic, in appropriate circumstances, ECT is bite and persists indefinitely.
safe and effective and may even be life-saving,
though temporary impairment of memory may
occur. Because the treatment was often misused Dermatoglyphics
in the past, it still carries a reputation that wor- Dermatoglyphics is the study of the patterns
ries patients and relatives; hence careful assess- made by the ridges and crevices of the hands
ment and counselling are essential before use is and the soles of the feet.
recommended.
Some patients with depression particularly Dermatologist
those with manic depression or who are a dan- A medically qualified specialist who diagnoses
ger to themselves or to the public, or who are and treats disorders of the skin (see SKIN, DIS-
suicidal may need admission to hospital, or in EASES OF).
severe cases to a secure unit, in order to initiate
treatment. But as far as possible patients are Dermatology
treated in the community (see MENTAL In essence, this is the study of the skin. As well
ILLNESS). as being an organ in its own right, the skin is a
stage on which other organs as well as the emo-
Depressor tions most visibly play out their roles. Changes
(1) A muscle that lowers or flattens a part of the in its blood vessels and hence blood flow
body. through the skin may indicate a major
(2) The name given to a nerve by whose stimu- immunological response to a range of potential
lation motion, secretion, or some other func- factors (see SKIN, DISEASES OF).
tion is restrained or prevented: for example, the
depressor nerve of the heart slows the beating of Dermatome
this organ. (1) Embryological tissue which has developed
from the somites to become the dermis and
Deprivation Score subcutaneous tissue. The cutaneous area that is
A measure of an individuals or groups lack of derived from each dermatome is supplied by a
normal social amenities such as proper housing, single dorsal spinal nerve root.
 Dextran 193

(2) A surgical instrument for removing very Detergents

thin slices of skin for grafting. Substances which clean the skin surface. This
means that, strictly speaking, any soap, or soap-
Dermatomyositis like substance used in washing, is a detergent.
A rare disease, possibly caused by an auto- At the present day, however, the term is largely
immune reaction, in which muscle inflam- used for the synthetic detergents which are now
mation and weakness is associated with a used on such a large scale. These are prepared
characteristic heliotrope ERYTHEMA of the face by the cracking and oxidation of high-petrol- D
and backs of the hands. In adults it may be eum waxes with sulphuric acid. The commoner
associated with underlying malignancy. Tissue ones in commercial preparations are aryl alkyl
changes are similar to those in POLYMYOSITIS. sulphate or sulphonate and secondary alkyl
sulphate.
Dermatophytes In view of their widespread use, such
Fungi which can infect skin, hair and nails. detergents appear to cause relatively little
About 30 species in three genera are PATHO- trouble with the skin, but more trouble has
GENIC to humans (see RINGWORM). been reported with the so-called biological
detergents named because they contain an
Dermographism ENZYME which destroys protein. As a result they
Dermographism, or factitious URTICARIA, refers are claimed to remove proteins (stains such as
to transient ERYTHEMA and wealing caused by blood, chocolate, milk or gravy) which are
trauma to the skin. relatively difficult for ordinary detergents to
remove. Unfortunately these biological
Dermoid Cyst detergents may cause dermatitis. In addition,
See CYSTS. they have been reported to cause asthma in
those using them, and even more so in workers
Desensitisation manufacturing them.
In psychiatry, a method for treating phobias
used in BEHAVIOUR THERAPY. The affected Detoxication
individual is slowly acclimatised to the cause of Also called detoxification, this is a process
his or her fear. (See also ALLERGY.) whereby toxic agents are removed from the
body and toxic effects neutralised. (See POISONS
Desferrioxamine and TOXINS.)
An agent which binds to heavy metals, used
in the treatment of iron poisoning and Deviance
THALASSAEMIA. Variation from normal. Often used to describe
unusual sexual behaviour.
Designer Drugs
A group of chemical substances produced Dexamethasone
illegally whose properties and effects are similar A CORTICOSTEROIDS derivative. As an anti-
to those of drugs of abuse. They may be inflammatory agent it is approximately 30
derived from narcotic ANALGESICS, AMPHET- times as effective as cortisone and eight times
AMINES or HALLUCINOGENS. Ecstasy is a widely as effective as prednisolone. On the other hand,
used designer drug and has caused deaths it has practically none of the salt-retaining
among teenagers. Designer drugs are poten- properties of cortisone.
tially dangerous, especially if taken with
alcohol. Dexamphetamine
A drug that stimulates the central nervous sys-
Desquamation tem. It can be used to treat NARCOLEPSY and
The scaling-off of the superficial layer of the hyperactive children but should not be used to
epidermis (see SKIN). combat obesity or treat depression. It is also a
drug of abuse.
Detached Retina
Separation of the retina from the choroid in the Dextran
EYE. It may be due to trauma or be secondary The name given to a group of polysaccharides
to tumour or inflammation of the choroid, first discovered in sugar-beet preparations
and causes blindness in the affected part of which had become infected with certain
the retina. It can be treated surgically using bacteria. A homogenous preparation of dextran,
PHOTOCOAGULATION. with a consistent molecular weight and free
 194 Dextrocardia

from PROTEIN, is in appropriate clinical circum- betes insipidus. Metabolic abnormalities such
stances used as a substitute for plasma for as HYPERCALCAEMIA and potassium depletion
TRANSFUSION purposes. Dextran is often used render the renal tubule less sensitive to vaso-
as an immediate transfusion measure to treat pressin, and certain drugs such as lithium and
severe bleeding or certain types of shock until tetracycline may have a similar effect.
properly cross-matched blood is available. A If the disease is due to a deficiency of vaso-
blood sample for cross-matching must be taken pressin, treatment should be with the analogue
D before intravenous dextran is given. of vasopressin called desmopressin which is
more potent than the natural hormone and has
Dextrocardia less pressor activity. It also has the advantage in
A condition in which a persons heart is situated that it is absorbed from the nasal mucosa and so
on the right of the chest in a mirror image of its does not need to be injected.
usual position. This may be associated with Nephrogenic diabetes insipidus cannot be
similar inversion of the abdominal organs treated with desmopressin. The urine volume
situs inversus. can, however, usually be reduced by half by a
thiazide diuretic (see THIAZIDES).
Dextromethophan
An over-the-counter drug used to relieve dry, Diabetes Mellitus
irritating, persistent coughs, this opioid acts as a Diabetes mellitus is a condition characterised
cough suppressant. It is available either alone or by a raised concentration of glucose in the
in combination with other drugs in linctus, blood due to a deficiency in the production
lozenges and syrups prepared to provide and/or action of INSULIN, a pancreatic hormone
symptomatic relief for coughs and colds. made in special cells called the islet cells of
Langerhans.
Dextrose Insulin-dependent and non-insulin-
Another name for purified grape sugar or glu- dependent diabetes have a varied pathological
cose. A common constituent of intravenous pattern and are caused by the interaction of
fluids. several genetic and environmental factors.

Dia- Insulin-dependent diabetes mellitus

Dia- is a prefix meaning through or thoroughly. (IDDM) (juvenile-onset diabetes, type 1 dia-
betes) describes subjects with a severe deficiency
Diabetes Insipidus or absence of insulin production. Insulin ther-
Diabetes insipidus is a relatively rare condition apy is essential to prevent KETOSIS a disturb-
and must be differentiated from DIABETES MEL- ance of the bodys acid/base balance and an
LITUS which is an entirely different disease. accumulation of ketones in the tissues. The
It is characterised by excessive thirst and the onset is most commonly during childhood, but
passing of large volumes of urine which have a can occur at any age. Symptoms are acute and
low specific gravity and contain no abnormal weight loss is common.
constituents. It is either due to a lack of the
antidiuretic hormone normally produced by Non-insulin-dependent diabetes mel-
the HYPOTHALAMUS and stored in the posterior litus (NIDDM) (maturity-onset diabetes,
PITUITARY GLAND, or to a defect in the renal type 2 diabetes) may be further sub-divided
tubules which prevents them from responding into obese and non-obese groups. This type
to the antidiuretic hormone VASOPRESSIN. usually occurs after the age of 40 years with an
When the disorder is due to vasopressin insuffi- insidious onset. Subjects are often overweight
ciency, a primary or secondary tumour in the and weight loss is uncommon. Ketosis rarely
area of the pituitary stalk is responsible for one- develops. Insulin production is reduced but not
third of cases. In another one-third of cases absent.
there is no apparent cause, and such IDIO- A new hormone has been identified linking
PATHIC cases are sometimes familial. A further obesity to type 2 diabetes. Called resistin
one-third of cases result from a variety of lesions because of its resistance to insulin it was first
including trauma, basal MENINGITIS and granu- found in mice but has since been identified in
lomatous lesions in the pituitary-stalk area. humans. Researchers in the United States
When the renal tubules fail to respond to vaso- believe that the hormone may, in part, explain
pressin this is usually because of a genetic defect how obesity predisposes people to diabetes.
transmitted as a sex-linked recessive character- Their hypothesis is that a protein in the bodys
istic, and the disease is called nephrogenic dia- fat cells triggers insulin resistance around the
 Diabetes Mellitus 195

body. Other research suggests that type 2 dia- sulphonylureas. Metformins main actions are
betes may now be occurring in obese children; to lower the production of glucose by the liver
this could indicate that children should be eat- and improve its uptake in the peripheral tissues.
ing a more-balanced diet and taking more
exercise. Complications The risks of complications
increase with duration of disease.
Diabetes associated with other con-
ditions (a) Due to pancreatic disease for Diabetic hypoglycaemia occurs when
example, chronic pancreatitis (see PANCREAS, D
amounts of glucose in the blood become low.
DISORDERS OF); (b) secondary to drugs for This may occur in subjects taking sulphonylu-
example, GLUCOCORTICOIDS (see PANCREAS, reas or insulin. Symptoms usually develop when
DISORDERS OF); (c) excess hormone production the glucose concentration falls below 25
for example, growth hormone (ACRO- mmol/l. They may, however, occur at higher
MEGALY); (d) insulin receptor abnormalities; (e) concentrations in subjects with persistent
genetic syndromes (see GENETIC DISORDERS). hyperglycaemia an excess of glucose and at
lower levels in subjects with persistent hypo-
Gestational diabetes Diabetes occurring glycaemia. Symptoms include confusion, hun-
in pregnancy and resolving afterwards. ger and sweating, with coma developing if
Aetiology Insulin-dependent diabetes oc- blood-sugar concentrations remain low.
curs as a result of autoimmune destruction of Refined sugar followed by complex carbo-
beta cells within the PANCREAS. Genetic influ- hydrate will return the glucose concentration to
ences are important and individuals with cer- normal. If the subject is unable to swallow, glu-
tain HLA tissue types (HLA DR3 and HLA cagon may be given intramuscularly or glucose
DR4) are more at risk; however, the risks intravenously, followed by oral carbohydrate,
associated with the HLA genes are small. If one once the subject is able to swallow.
parent has IDDM, the risk of a child develop- Although it has been shown that careful con-
ing IDDM by the age of 25 years is 1525 per trol of the patients metabolism prevents late
cent, and the risk of a sibling of an IDDM complications in the small blood vessels, the
subject developing diabetes is about 3 per cent. risk of hypoglycaemia is increased and patients
Non-insulin-dependent diabetes has no need to be well motivated to keep to their diet-
HLA association, but the genetic influences are ary and treatment regime. This regime is also
much stronger. The risks of developing diabetes very expensive. All risk factors for the patients
vary with different races. Obesity, decreased cardiovascular system not simply controlling
exercise and ageing increase the risks of disease hyperglycaemia may need to be reduced if late
development. The risk of a sibling of a complications to the cardiovascular system are
NIDDM subject developing NIDDM up to to be avoided.
the age of 80 years is 3040 per cent. Diabetes is one of the worlds most serious
health problems. Recent projections suggest
Diet Many NIDDM diabetics may be treated that the disorder will affect nearly 240 million
with diet alone. For those subjects who are individuals worldwide by 2010 double its
overweight, weight loss is important, although prevalence in 1994. The incidence of insulin-
often unsuccessful. A diet high in complex dependent diabetes is rising in young children;
carbohydrate, high in fibre, low in fat and aim- they will be liable to develop late complications.
ing towards ideal body weight is prescribed. Although there are complications associated
Subjects taking insulin need to eat at regular with diabetes, many subjects live normal lives
intervals in relation to their insulin regime and and survive to an old age. People with diabetes
missing meals may result in hypoglycaemia, a or their relatives can obtain advice from
lowering of the amount of glucose in the Diabetes UK (www.diabetes.org.uk).
blood, which if untreated can be fatal (see
below). Increased risks are present of (a) heart dis-
ease, (b) peripheral vascular disease, and (c)
Oral hypoglycaemics are used in the cerebrovascular disease.
treatment of non-insulin-dependent diabetes in
addition to diet, when diet alone fails to control Diabetic eye disease (a) retinopathy, (b)
blood-sugar levels. (a) SULPHONYLUREAS act cataract. Regular examination of the fundus
mainly by increasing the production of insulin; enables any abnormalities developing to be
(b) BIGUANIDES, of which only metformin is detected and treatment given when appropriate
available, may be used alone or in addition to to preserve eyesight.
 196 Diagnosis

Nephropathy Subjects with diabetes may Insulin All insulin is injected mainly by syr-
develop kidney damage which can result in inge but sometimes by insulin pump because
renal failure. it is inactivated by gastrointestinal enzymes.
There are three main types of insulin prepar-
Neuropathy (a) Symmetrical sensory ation: (a) short action (approximately six
polyneuropathy; damage to the sensory nerves hours), with rapid onset; (b) intermediate
that commonly presents with tingling, numb- action (approximately 12 hours); (c) long
D ness of pain in the feet or hands. (b) Asym- action, with slow onset and lasting for up to 36
metrical motor diabetic neuropathy, presenting hours. Human, porcine and bovine prepar-
as progressive weakness and wasting of the ations are available. Much of the insulin now
proximal muscles of legs. (c) Mononeuropathy; used is prepared by genetic engineering tech-
individual motor or sensory nerves may be niques from micro-organisms. There are many
affected. (d) Autonomic neuropathy, which regimens of insulin treatment involving differ-
affects the autonomic nervous system, has many ent combinations of insulin; regimens vary
presentations including IMPOTENCE, diarrhoea depending on the requirements of the patients,
or constipation and postural HYPOTENSION. most of whom administer the insulin them-
selves. Carbohydrate intake, energy expenditure
Skin lesions There are several skin disorders and the presence of infection are important
associated with diabetes, including: (a) necro- determinants of insulin requirements on a
biosis lipoidica diabeticorum, characterised by day-to-day basis.
one or more yellow atrophic lesions on the legs; A new treatment for diabetes, pioneered
(b) ulcers, which most commonly occur on the in Canada and entering its preliminary
feet due to peripheral vascular disease, neur- clinical trials in the UK, is the transplantation
opathy and infection. Foot care is very of islet cells of Langerhans from a healthy
important. person into a patient with the disorder. If
the transplantation is successful, the trans-
Diabetic ketoacidosis occurs when there planted cells start producing insulin, thus
is insufficient insulin present to prevent reducing or eliminating the requirement for
KETONE production. This may occur before the regular insulin injections. If successful the trials
diagnosis of IDDM or when insufficient insulin would be a significant advance in the treatment
is being given. The presence of large amounts of of diabetes.
ketones in the urine indicates excess ketone Scientists in Israel have developed a drug,
production and treatment should be sought Dia Pep 277, which stops the bodys immune
immediately. Coma and death may result if the system from destroying pancratic cells as
condition is left untreated. happens in insulin-dependent diabetes. The
drug, given by injection, offers the possibility of
preventing type 1 diabetes in healthy people at
Symptoms Thirst, POLYURIA, GLYCOSURIA, genetic risk of developing the disorder, and of
weight loss despite eating, and recurrent checking its progression in affected individuals
infections (e.g. BALANITIS and infections of the whose cells are already perishing. Trials of the
VULVA) are the main symptoms. drug are in progress.
However, subjects with non-insulin-
dependent diabetes may have the disease for
several years without symptoms, and diagnosis Diagnosis
is often made incidentally or when presenting The skill of distinguishing one disease from
with a complication of the disease. another; it is essential to scientific and success-
ful treatment. The name is also given to the
Treatment of diabetes aims to prevent opinion arrived at as to the nature of a disease.
symptoms, restore carbohydrate metabolism to It is in diagnosis more than in treatment that
as near normal as possible, and to minimise the highest medical skill is required, and, for a
complications. Concentration of glucose, fruc- diagnosis, the past and hereditary history of a
tosamine and glycated haemoglobin in the case, the symptoms complained of, and the
blood are used to give an indication of blood- signs of disease found upon examination are
glucose control. all weighed. Many methods of laboratory
Insulin-dependent diabetes requires insulin examination are also used at the present day in
for treatment. Non-insulin-dependent diabetes aiding diagnosis. Computers are also being
may be treated with diet, oral HYPOGLYCAEMIC used to help clinical and laboratory diagnostic
AGENTS or insulin. procedures.
 Diarrhoea 197

Dialysis dialysis carry a relatively high morbidity and the

A procedure used to filter off waste products ideal treatment for patients with end-stage renal
from the blood and remove surplus fluid from failure is successful renal TRANSPLANTATION.
the body in someone who has kidney failure (see
KIDNEYS, DISEASES OF). The scientific process Diamorphine
involves separating crystalloid and COLLOID Diamorphine is another name for HEROIN.
substances from a solution by interposing a
semi-permeable membrane between the solu- Diaphoresis D
tion and pure water. The crystalloid substances Another name for sweating (see PERSPIRATION).
pass through the membrane into the water until
a state of equilibrium, so far as the crystalloid Diaphragm
substances are concerned, is established The diaphragm is the thin, dome-shaped mus-
between the two sides of the membrane. The cular partition which separates the cavity of the
colloid substances do not pass through the abdomen from that of the chest. It is of great
membrane. importance in respiration, playing the chief part
Dialysis is available as either haemodialysis or in filling the lungs. During deep respiration its
peritoneal dialysis. movements are responsible for 60 per cent of
the total amount of air breathed, and in the
Haemodialysis Blood is removed from the horizontal posture, or in sleep, an even greater
circulation either through an artificial arterio- percentage.
venous fistula (junction) or a temporary or The description diaphragm is also used for
permanent internal catheter in the jugular vein the hemispherical rubber (dutch) cap used in
(see CATHETERS). It then passes through an arti- conjunction with a chemical spermicide as a
ficial kidney (dialyser) to remove toxins (e.g. contraceptive. It fits over the neck of the
potassium and urea) by diffusion and excess salt uterus (cervix) inside the vagina. (See
and water by ultrafiltration from the blood into CONTRACEPTION.)
dialysis fluid prepared in a proportionator
(often referred to as a kidney machine). Dia- Diaphysectomy
lysers vary in design and performance but all The operation whereby a part of the shaft of a
work on the principle of a semi-permeable long bone (e.g. humerus, femur) is excised.
membrane separating blood from dialysis fluid.
Haemodialysis is undertaken two to three times Diaphysis
a week for 46 hours a session. The shaft of a long bone.

Peritoneal dialysis uses the peritoneal lin- Diarrhoea

ing (see PERITONEUM) as a semi-permeable Diarrhoea or looseness of the bowels is
membrane. Approximately 2 litres of sterile increased frequency, fluidity or volume of
fluid is run into the peritoneum through the bowel movements compared to usual. Most
permanent indwelling catheter; the fluid is left people have occasional attacks of acute diar-
for 34 hours; and the cycle is repeated 34 rhoea, usually caused by contaminated food or
times per day. Most patients undertake con- water or excessive alcohol consumption. Such
tinuous ambulatory peritoneal dialysis attacks normally clear up within a day or two,
(CAPD), although a few use a machine over- whether or not they are treated. Chronic diar-
night (continuous cycling peritoneal dialysis, rhoea, on the other hand, may be the result of a
CCPD) which allows greater clearance of serious intestinal disorder or of more general
toxins. disease.
The commonest cause of acute diarrhoea
Disadvantages of haemodialysis include car- is food poisoning, the organisms involved
diovascular instability, HYPERTENSION, bone usually being STAPHYLOCOCCUS, CLOSTRIDIUM
disease, ANAEMIA and development of peri- bacteria, salmonella, E. coli O157 (see
articular AMYLOIDOSIS. Disadvantages of ESCHERICHIA), CAMPYLOBACTER, crypto-
peritoneal dialysis include peritonitis, poor sporidium, and Norwalk virus. A person may
drainage of fluid, and gradual loss of overall also acquire infective diarrhoea as a result of
efficiency as endogenous renal function droplet infections from adenoviruses or echovi-
declines. Haemodialysis is usually done in ruses. Interference with the bacterial flora of the
outpatient dialysis clinics by skilled nurses, intestine may cause acute diarrhoea: this often
but some patients can carry out the procedure happens to someone who travels to another
at home. Both haemodialysis and peritoneal country and acquires unfamiliar intestinal
 198 Diastase

bacteria. Other infections include bacillary Diastase

dysentery, typhoid fever and paratyphoid fevers A mixture of enzymes obtained from malt.
(see ENTERIC FEVER). Drug toxicity, food allergy, These enzymes have the property of converting
food intolerance and anxiety may also cause starch into sugar. Diastase is used in the prepar-
acute diarrhoea, and habitual constipation may ation of predigested starchy foods, and in the
result in attacks of diarrhoea. treatment of DYSPEPSIA, particularly that due to
inability to digest starch adequately. It is also
D Treatment of diarrhoea in adults depends on used for the conversion of starch to fermentable
the cause. The water and salts (see ELECTRO- sugars in the brewing and fermentation
LYTES) lost during a severe attack must be industries.
replaced to prevent dehydration. Ready-
prepared mixtures of salts can be bought from a Diastasis
pharmacist. Antidiarrhoeal drugs such as A term applied to separation of the end of a
codeine phosphate or loperamide should be growing bone from the shaft. The condition
used in infectious diarrhoea only if the symp- resembles a fracture, but is more serious because
toms are disabling. Antibacterial drugs may be of the damage done to the growing cartilage
used under medical direction. Persistent diar- through which the separation takes place, so
rhoea longer than a week or blood-stained that the future growth of the bone is consider-
diarrhoea must be investigated under medical ably diminished.
supervision.
Diastole
Diarrhoea in infants can be such a serious The relaxation of a hollow organ. The term is
condition that it requires separate consider- applied in particular to the HEART, to indicate
ation. One of its features is that it is usually the resting period between the beats (systole),
accompanied by vomiting; the result can be while blood is flowing into the organ.
rapid dehydration as infants have relatively high
fluid requirements. Mostly it is causd by acute Diastolic Pressure
gastroenteritis caused by various viruses, most The pressure exerted by the blood against the
commonly ROTAVIRUSES, but also by many bac- arterial wall during DIASTOLE. This is the lowest
teria. In the developed world most children blood pressure in the cardiac cycle. A normal
recover rapidly, but diarrhoea is the single reading of diastolic pressure in a healthy adult
greatest cause of infant mortality worldwide. at rest is 70 mm Hg. (See HEART.)
The younger the infant, the higher the mortal-
ity rate. Diathermy
Diarrhoea is much more rare in breast-fed A process by which electric currents can be
babies, and when it does occur it is usually less passed into the deeper parts of the body so as to
severe. The environment of the infant is also produce internal warmth and relieve pain; or,
important: the condition is highly infectious by using powerful currents, to destroy tumours
and, if a case occurs in a maternity home or a and diseased parts bloodlessly. The form of elec-
childrens hospital, it tends to spread quickly. tricity used consists of high-frequency oscilla-
This is why doctors prefer to treat such children tions, the frequency of oscillation ranging from
at home but if hospital admission is essential, 10 million to 25,000 million oscillations per
isolation and infection-control procedures are second. The current passes between two elec-
necessary. trodes placed on the skin.
The so-called ultra-short-wave diathermy (or
Treatment An infant with diarrhoea should short-wave diathermy, as it is usually referred
not be fed milk (unless breast-fed, when this to) has replaced the original long-wave dia-
should continue) but should be given an elec- thermy, as it is produced consistently at a stable
trolyte mixture, available from pharmacists or wave-length (11 metres) and is easier to apply.
on prescription, to replace lost water and salts. In recent years microwave diathermy has been
If the diarrhoea improves within 24 hours, milk developed, which has a still higher oscillating
can gradually be reintroduced. If diarrhoea con- current (25,000 million cycles per second,
tinues beyond 3648 hours, a doctor should be compared with 500 million for short-wave
consulted. Any signs of dehydration require diathermy).
urgent medical attention; such signs include When the current passes, a distinct sensation
drowsiness, lack of response, loose skin, persist- of increasing warmth is experienced and the
ent crying, glazed eyes and a dry mouth and temperature of the body gradually rises; the
tongue. hearts action becomes quicker; there is sweat-
 Diet 199

ing with increased excretion of waste products. logical food chain with the result that animals
The general blood pressure is also distinctly at the end of the food chain such as birds or
lowered. The method is used in painful predators may build up lethal concentrations of
rheumatic conditions, both of muscles and the substance in their tissues.
joints. In any case, an increasing number of species
By concentrating the current in a small elec- of insects were becoming resistant to DDT.
trode, the heating effects immediately below Fortunately, newer insecticides have been
this are very much increased. The diathermy introduced which are toxic to DDT-resistant D
knife utilises this technique to coagulate bleed- insects, but there are doubts whether this sup-
ing vessels and cauterise abnormal tissue during ply of new insecticides can be maintained as
surgery. insects develop resistance to them.

Diathesis Dicrotism
An archaic term meaning constitutional or A condition in which the PULSE occurs as a beat
inherited state giving an individual a predis- each time the heart contracts. A dicrotic wave is
position towards a disease, a group of diseases naturally present in a tracing of any pulse as
or a structural or metabolic abnormality. An recorded by an instrument for the purpose, but
example is HAEMOPHILIA, a bleeding disorder. in health it is imperceptible to the finger. In
fevers, a dicrotic pulse is a serious sign in which
Diazepam the heart continues to beat violently while the
See TRANQUILLISERS; BENZODIAZEPINES. small blood vessels have lost their tone.

Dicephalus Didanosine
The term applied to symmetrical CONJOINED Didanosine (ddI, DDI) is a nucleoside reverse
TWINS with two separate heads. transcriptase inhibitor used to treat progressive
or advanced HIV infection (see AIDS/HIV).
Dichlorodiphenyl Preferably it should be given in combination
Trichloroethane with other antiretroviral drugs. This drug has
DDT is the generally used abbreviation for the a range of potentially serious side-effects such
compound which has been given the official as pancreatitis (see PANCREAS, DISEASES OF),
name of dicophane. It was first synthesised in peripheral NEUROPATHY, DIABETES MELLITUS
1874, but it was not until 1940 that, as a result and liver failure. Its use requires monitoring
of research work in Switzerland, its remarkable and patients taking it should receive
toxic action on insects was discovered. This counselling.
work was taken up and rapidly expanded in
Great Britain and the USA, and one of its first Dieldrin
practical applications was in controlling the An effective insecticide toxic to a wide range of
spread of TYPHUS FEVER. This disease is trans- insects. It attacks the insects nervous system
mitted by the louse, one of the insects for which and is more toxic to humans than DDT (see
DDT is most toxic. Its toxic action against the DICHLORODIPHENYL TRICHLOROETHANE), so
mosquito has also been amply proved, and it must therefore be handled with care. Its use in
thus rapidly became one of the most effective the UK is restricted.
measures in controlling MALARIA. DDT is toxic
to a large range of insects in addition to the Diencephalon
louse and the mosquito; these include house- Part of the forebrain (see BRAIN).
flies, bed-bugs, clothes-moths, fleas, cock-
roaches, and ants. It is also active against many Dienoestrol
agricultural and horticultural pests, including A synthetic oestrogen closely related to STIL-
weevils, flour beetles, pine sawfly, and most var- BOESTROL. It is not as potent as stilboestrol, but
ieties of scale insect. is less toxic and is used as a cream to treat
DDT has thus had a wide use in medicine, vaginal dryness.
public health, veterinary medicine, horti-
culture, and agriculture. Unfortunately, the Diet
indiscriminate use of DDT is potentially haz- The mixture of food and drink consumed by an
ardous, and its use is now restricted or banned individual. Variations in morbidity and mortal-
in several countries, including the United ity between population groups are believed
Kingdom. to be due, in part, to differences in diet. A
The danger of DDT is that it enters the bio- balanced diet was traditionally viewed as one
 200 Dietetics

which provided at least the minimum require- altered. A commercially available or home-
ment of energy, protein, vitamins and minerals made liquid diet can be used to provide all or
needed by the body. However, since nutritional some of a patients nutritional needs if neces-
deficiencies are no longer a major problem in sary. Although the enteral (by mouth) route is
developed countries, it seems more appropriate the preferred route for feeding and can be
to consider a healthy diet as being one which used for most patients, parenteral or intraven-
provides all essential nutrients in sufficient ous feeding is occasionally required in a
D quantities to prevent deficiencies but which also minority of patients whose gastrointestinal
avoids health problems associated with nutrient tract is unavailable or unreliable over a period
excesses. of time.
Major diet-related health problems in pros- A wide variety of weight-reducing diets are
perous communities tend to be the result of well publicised. People should adopt them
dietary excesses, whereas in underdeveloped, with caution and, if in doubt, seek expert
poor communities, problems associated with advice.
dietary deficiencies predominate. Excessive
intakes of dietary energy, saturated fats, sugar, Dietetics
salt and alcohol, together with an inadequate Dietitians apply dietetics, the science of nutri-
intake of dietary fibre, have been linked to the tion, to the feeding of groups and individuals in
high prevalence of OBESITY, cardiovascular dis- health and disease. Their training requires a
ease, dental caries, HYPERTENSION, gall-stones degree course in the nutritional and biological
(see GALL-BLADDER, DISEASES OF), non-insulin- sciences. The role of the dietitian can be divided
dependent DIABETES MELLITUS and certain as follows.
cancers (e.g. of the breast, endometrium, intes-
tine and stomach) seen in developed nations. Preventive By liaising with health education
Health-promotion strategies in these countries departments, schools and various groups in the
generally advocate a reduction in the intake of community. They plan and provide nutrition
fat, particularly saturated fat, and salt, the education programmes including in-service
avoidance of excessive intakes of alcohol and training and the production of educational
simple sugars, an increased consumption of material in nutrition. They are encouraged to
starch and fibre and the avoidance of obesity by plan and participate in food surveys and
taking appropriate physical exercise. A max- research projects which involve the assessment
imum level of dietary cholesterol is sometimes of nutritional status.
specified.
Undernutrition, including protein-energy
Therapeutic Their role is to advise patients
malnutrition and specific vitamin and mineral
who require specific dietary therapy as all or
deficiencies, is an important cause of poor
part of their treatment. They teach patients in
health in underdeveloped countries. Priorities
hospitals to manage their own dietary treat-
here centre on ensuring that the diet provides
ment, and ensure a supportive follow-up so that
enough nutrients to maintain health.
patients and their families can be seen to be
In healthy people, dietary requirements
coping with the diet. Therapeutic dietitians fur-
depend on age, sex and level of physical activity.
ther advise catering departments on the adapta-
Pregnancy and lactation further alter require-
tion of menus for individual diets and on the
ments. The presence of infections, fever, burns,
nutritional value of the food supplied to
fractures and surgery all increase dietary energy
patients and staff. They advise social-services
and protein requirements and can precipitate
departments so that meals-on-wheels provision
undernutrition in previously well-nourished
has adequate nutritional value.
people.
In addition to disease prevention, diet has a
role in the treatment of certain clinical dis- Industry The advice of dietitians is sought by
orders, for example, obesity, diabetes mellitus, industry in the production of product informa-
HYPERLIPIDAEMIA, inborn errors of metabol- tion literature, data sheets and professional leaf-
ism, food intolerances and hepatic and renal lets for manufacturers of ordinary foods and
diseases. Therapeutic diets increase or restrict specialist dietetic food. They give advice to the
the amount and/or change the type of fat, manufacturers on nutritional and dietetic
carbohydrate, protein, fibre, vitamins, min- requirements of their products.
erals and/or water in the diet according to
clinical indications. Additionally, the consist- Diethylcarbamazine Citrate
ency of the food eaten may need to be A FILARICIDE derived from PIPERAZINE used to
 Dioptre 201

treat FILARIASIS a group of diseases caused by terminate a pregnancy or to clean out the
parasitic worms called nematode filariae. uterus after a partial miscarriage. D and C is
increasingly being replaced with a LASER tech-
Dietitian nique using a hysteroscope a type of
See DIETETICS. ENDOSCOPE.

Differential Diagnosis Dilator

A list of the possible diagnoses that might (1) A muscle which has the action of increasing D
explain a patients symptoms and signs, and the diameter of an organ or vessel.
from which the correct DIAGNOSIS will be (2) A drug which usually acts by relaxing
extracted after further investigations. smooth muscle to increase the diameter of
blood vessels, the bronchial tree, or other
Differentiation organs.
The gradual diversification of the STEM CELLS (3) An instrument used to increase the diameter
of the early EMBRYO into the specialised cells, of an orifice or organ, either to treat a stricture
tissues and organs that go to make up the fully or to allow surgical access.
developed organism.
Diltiazem
Digestion One of the CALCIUM-CHANNEL BLOCKERS,
The three processes by which the body effective in most types of ANGINA; however, it
incorporates food are digestion, ABSORPTION, should not be given to patients with heart fail-
and ASSIMILATION. In digestion, food is soft- ure. A longer-acting version of the drug can be
ened and converted into a form soluble in the used in HYPERTENSION.
watery fluids of the body; or, in the case of fat,
into minute globules. The substances formed Diluents
are then absorbed from the bowels and carried Diluents are watery fluids of a non-irritating
throughout the body by the blood. In assimila- nature, which are given to increase the amount
tion, these substances, deposited from the of perspiration or of urine, and carry solids with
blood, are used by the various tissues for their them from the system. Examples are water,
growth and repair. milk, barley-water, and solutions of alkaline
salts.
Digoxin
One of a number of drugs known as CARDIAC Dimenhydrinate
GLYCOSIDES. They increase the contractility of Dimenhydrinate, or dramamine, is an anti-
heart muscle, depress the conducting tissue histamine drug, obtainable without prescrip-
while increasing myocardial excitability, and tion, to prevent and treat travel sickness.
increase activity of the VAGUS nerve. Digoxin is
usually given orally for the treatment of atrial Dimercaprol
FIBRILLATION and heart failure. The adverse Also called British Anti-Lewisite (BAL), this is a
effects of overdosage (which occur more com- chelating agent used in the treatment of metal
monly in people with HYPOKALAEMIA, the eld- poisoning (e.g. arsenic, lead, mercury). It has a
erly, and those with renal failure see KIDNEYS, high incidence of side-effects and is now only
DISEASES OF) are vomiting, DYSRHYTHMIA, rarely used as it has been superseded by less
muscle weakness, and visual disturbances. The toxic chelating agents.
ELECTROCARDIOGRAM (ECG) has a character-
istic appearance. Dioctyl Sodium Sulphosuccinate
See DOCUSATE SODIUM.
Dihydrocodeine
An analgesic drug with similar efficacy to Diodone
CODEINE. A complex, radio-opaque, organic, iodine-
containing preparation, used for contrast radi-
Dilatation and Curettage ography of parts of the body in particular, the
Commonly referred to as D and C, a gynaeco- urinary tract (see PYELOGRAPHY).
logical operation to scrape away the lining of
the UTERUS (ENDOMETRIUM). The procedure Dioptre
may be used to diagnose and treat heavy bleed- A term used in the measurement of the refract-
ing from the womb (ENDOMETRIOSIS) as well ive or focusing power of lenses; one dioptre is
as other uterine disorders. It can be used to the power of a lens with a focal distance of one
 202 Diphenhydramine

metre and is the unit of refractive power. As a Diplococcus

stronger lens has a greater refractive power, this A group of spherical bacterial organisms which
means that the focal distance will be shorter. usually occur in pairs: for example, pneumo-
The strength in dioptres therefore is the cocci. (See BACTERIA.)
reciprocal of the focal length expressed in
metres. Diplo
The layer of spongy bone which intervenes
D Diphenhydramine between the compact outer and inner tables of
A widely used antihistamine (see ANTI- the skull.
HISTAMINE DRUGS) with sedative effects.
Diploid
Diphenoxylate An adjective describing cells, nuclei or organ-
Also known as cophentrope or Lomotil. isms in which every chromosome apart from
When mixed with ATROPINE sulphate, it is used the Y sex one is represented twice.
as tretament for adult patients with DIAR-
RHOEA, particularly if chronic. It has no anti- Diplopia
bacterial properties but is sometimes used to Double vision. It is due to some irregularity in
treat travellers diarrhoea. action of the muscles which move the eyeballs,
in consequence of which the eyes are placed so
Diphtheria that rays of light from one object do not fall
Diphtheria is an acute infectious disease of the upon corresponding parts of the two retinae,
respiratory tract. Rarely seen in the UK since and two images are produced. It is a symptom
the introduction of inoculation in 1940, it is of several nervous diseases, and often a
still an important cause of disease in many parts temporary attack follows an injury to the eye,
of the world. The infection is caused by the intoxication, or some febrile disease like
Corynebacterium diphtheriae and is spread by DIPHTHERIA.
water droplets. It usually presents with a sore
throat, and there is a slightly raised membrane Diprosopus
on the tonsils surrounded by an inflammatory The term applied to a FETUS which has two
zone. There may be some swelling of the neck faces instead of one.
and lymph nodes, though the patients tem-
perature is seldom much raised. Occasionally Dipsomania
the disease occurs in the eye or genital tract, or A morbid and insatiable craving for ALCOHOL.
it may complicate lesions of the skin. More ser-
ious consequences follow the absorption of Dipygus
TOXINS which damage the heart muscle and the A FETUS with a double PELVIS.
nervous system.
Disability
Treatment Provided that the patient is not An observable mental or physical loss or
allergic to horse serum, an injection of the impairment which is measurable and which
antitoxin is given immediately. A one-week may be permanent or temporary. If the dis-
course of penicillin is started (or erythromycin ability is serious enough to affect a persons
if the patient is allergic to penicillin). Diph- normal function adversely, it is described as a
theria may cause temporary muscle weakness handicap.
or paralysis, which should resolve without spe-
cial treatment; if the respiratory muscles are Disabled Persons
involved, however, artificial respiration may be Disabled persons in the United Kingdom have
necessary. a range of services and financial support avail-
All infants should be immunised against able to help them to lead as normal and active a
diphtheria; for details see table under life as possible. Officially, the disabled include
IMMUNISATION. those with significant impairment of any kind,
including impairment of sight and hearing,
Diplegia learning difficulties, and chronic illness as well
Extensive PARALYSIS on both sides of the body as disablement due to accidents and the like.
but affecting the legs more than the arms.
Social services are provided by local-
Diplo- authority social-services departments. They
A prefix meaning twofold. include: practical help in the home (usually
 Dislocations 203

through home helps or aids to daily living); tion, other than those arising directly from
assistance in taking advantage of available edu- physical injury.
cational facilities; help with adaptations to the
disabled persons house; provision of meals Disinfectants
(Meals on Wheels or luncheon centres); and Substances that destroy micro-organisms, thus
help in obtaining a telephone. Many of these preventing them from causing infections. The
facilities will involve the disabled person in name is usually applied to powerful chemicals
some expense, but full details can be obtained that are also capable of destroying tissue and so D
from the local social-services department which are used only to sterilise inanimate surfaces.
will, if necessary, send a social worker to discuss ANTISEPTICS are used to cleanse living tissues.
the matter in the disabled persons home.
Owing to lack of funds and staff, many local- Disinfection
authority social-services departments are unable Processes by which vegetative organisms,
to provide the full range of services. excluding spores, are killed in order to prevent
the items disinfected from passing on infection.
Aids to daily living There is now a wide Equipment, bedlinen and hard surfaces may all
range of aids for the disabled. Full details and be disinfected the method chosen will
addresses of local offices can be obtained from: depend on the material and size of the object.
Disabled Living Foundation and British Red One of the most important procedures in pre-
Cross. venting the spread of infection is the careful
washing of hands before handling equipment
Aids to mobility and transport Some and between treating different patients. STERIL-
car manufacturers make specially equipped or ISATION is different from disinfection in that
adapted cars, and some have official systems for the methods used kill all living organisms and
discounts. Details can be obtained from local spores.
dealers. Help can also be obtained from Mota-
bility, which provides advice. Methods of disinfection (1) Skin,
wounds, etc. chlorhexidine (with detergent or
Disarticulation spirit); iodine (with detergent or spirit); cetrim-
The amputation of a bone by cutting through ide; ethyl alcohol; all must stay in contact with
the joint of which the bone forms a part. the skin for long enough for bacteria to be
killed. (2) Hard surfaces (floors, walls, etc.)
Disc hypochlorites (i.e. bleaches) with or without
An anatomical term describing a rounded flat- detergent; cetrimide; iodine-containing solu-
tened structure. Examples are the cartilagenous tions; ethyl alcohol. (3) Equipment wet or dry
disc positioned between two vertebrae (see heat (e.g. boiling for more than 5 minutes);
SPINAL COLUMN) and the optic disc (see EYE). submersion in liquid disinfectants for the
appropriate time (e.g. glutaraldehyde 25 per
Discharge cent), chlorhexidine in spirit 70 per cent, for-
Abnormal emission or emissions from any part maldehyde (irritant), chlorhexidine (01 per
of the body. It usually applies to purulent cent aqueous), hypochlorites.
material for example, the septic material
which comes away from an infected ear, or nose Disinfestation
but can be the result of excess secretions from The destruction of insect pests, especially lice,
the mucous linings of the vagina or rectum. whether on the person or in dwelling-places.

Discission Dislocations
The term applied to an operation for destroying Injuries to joints of such a nature that the
a structure by tearing it without removal: for ends of the opposed bones are forced more or
example, the operation of needling the lens of less out of connection with one another.
the eye for cataract (see EYE, DISORDERS OF). Besides displacement of the bones, there is
bruising of the tissues around them, and tear-
Discoid Lupus Erythematosus ing of the ligaments which bind the bones
(DLE) together.
See under LUPUS. Dislocations, like fractures (see BONE, DIS-
ORDERS OF), are divided into simple and com-
Disease pound, the bone in the latter case being forced
Any abnormality of bodily structure or func- through the skin. This seldom occurs, since
 204 Disodium Cromoglycate

the round head of the bone has not the same Dyspraxia
power to wound as the sharp end of a broken See APRAXIA.
bone. Dislocations are also divided according
to whether they are (1) congenital, i.e. present Dissection
at birth in consequence of some malformation, (1) The cutting of tissue to separate the struc-
or (2) acquired at a later period in con- tural components for identification or removal
sequence of injury, the great majority falling during an operation or the study of anatomy.
D into the latter class. The reduction of a dis- (2) Dissection of an artery involves tearing of
located joint is a skilled procedure and should the inner part of the wall, allowing blood to
be done by an appropriately trained track through the media occluding the origins
professional. of smaller arteries and often leading to vessel
rupture (see also ARTERIES).
Disodium Cromoglycate
A drug used in the prophylactic (preventive) Disseminated
treatment of allergic disorders (see ALLERGY), Spread of disease from its original site through-
particularly ASTHMA, conjunctivitis (see EYE, out an organ or the body. Often used to
DISORDERS OF), nasal allergies, and food describe the spread of CANCER.
allergies especially in children. Although
inappropriate for the treatment of acute attacks Disseminated Sclerosis
of asthma, regular inhalations of the drug can See MULTIPLE SCLEROSIS (MS).
reduce its incidence, and allow the dose of
BRONCHODILATORS and oral CORTICO- Dissociation
STEROIDS to be cut. A psychiatric term describing the process
whereby an individual separates his or her ideas
Disopyramide and thoughts from consciousness, thus allowing
One of the ANTIARRHYTHMIC DRUGS given by them to function independently. The result
intravenous injection after myocardial infarc- may be that the individual holds contrary views
tion to restore supraventricular and ventricular on the same subject.
arrhythmias to normal, particularly when
patients have not responded to lidocaine (ligno- Dissociative Disorder
caine). It can impair the contractility of heart A collection of psychological disorders in which
muscle and it does have an antimuscarinic a particular mental function becomes cut off
effect (see ANTIMUSCARINE); consequently its from a persons mind. Hysterical AMNESIA is
administration has to be undertaken with care, one example, when the person forgets his or her
especially in patients with GLAUCOMA or personal history but can still absorb and talk
enlargement. about new events. Other examples are FUGUE,
depersonalisation (detachment from self and
Disorientation environment), and MULTIPLE PERSONALITY
Orientation in a clinical sense includes a per- DISORDER.
sons awareness of time and place in relation to
him- or herself and others, the recognition of Distal
personal friends and familiar places, and the An adjective applied to a body part that is fur-
ability to remember at least some past experi- ther away from another part, with reference, for
ence and to register new data. It is therefore example, to the trunk.
dependent on the ability to recall all learned
memories and make effective use of memory. Distichiasis
Disorientation can be the presenting feature of Distichiasis is the term applied to the condition
both DELIRIUM (confusion) and DEMENTIA; in which there are two complete rows of eye-
delirium is reversible, developing dramatically lashes in one eyelid (or in both).
and accompanied by evidence of systemic dis-
ease, while dementia is a gradually evolving, Distoma
irreversible condition. Distoma is a general term including various
forms of trematodes, or fluke-worms, parasitic
Displacement in the intestine, lung and other organs.
A term used in psychological medicine to
describe the mental process of attaching to one Disulfiram
object, painful emotions associated with Disulfiram is used as an adjunct in the treat-
another object. ment of alcoholism. It is relatively non-toxic by
 Dizygotic Twins 205

itself, but when taken in conjunction with (d) drugs acting on the distal tubule prevent
alcohol it produces most unpleasant effects: for sodium reabsorption by retaining potassium
example, flushing of the face, palpitations, a (e.g. spironalactone).
sense of oppression and distress, and ultimately
sickness and vomiting. The rationale of treat- Diverticular Disease
ment therefore is to give the alcoholic subject a The presence of numerous diverticula (sacs or
course of disulfiram and then demonstrate, by pouches) in the lining of the COLON accom-
letting him or her take some alcoholic liquor, panied by spasmodic lower abdominal pain and
erratic bowel movements. The sacs may become
D
how unpleasant are the effects. If the patient is
co-operative, the treatment may be effective, inflamed causing pain (see DIVERTICULITIS).
but there is some risk so it must be given under
skilled medical supervision. Diverticulitis
Inflammation of diverticula (see DIVERTICULUM)
Disuse Atrophy in the large intestine. It is characterised by pain
The wasting of muscles after prolonged in the left lower side of the abdomen, which has
immobility. This can be seen after lengthy been aptly described as left-sided appendicitis
immobilisation in a plaster cast, and is particu- as it resembles the pain of appendicitis but
larly severe following paralysis of a limb occurs in the opposite side of the abdomen. The
through nerve injury. (See ATROPHY.) onset is often sudden, with fever and constipa-
tion. It may, or may not, be preceded by
Dithranol DIVERTICULOSIS. Treatment consists of rest, no
A drug used to treat PSORIASIS. It is usually very solid food but ample fluid, and the administra-
effective, being applied normally for short con- tion of tetracycline. Complications are unusual
tact periods of up to 1 hour. Dithranol can but include ABSCESS formation, perforation of
cause severe skin irritation so must be used with the colon, and severe bleeding.
care and at appropriate concentrations. Hands
should be thoroughly washed after use.
Diverticulosis
The presence of diverticula (see DIVERTICULUM)
or sacs in the large intestine. Such diverticula are
Diuresis not uncommon over the age of 40, increasing
An increase in the production of urine. This with age until over the age of 70 they may be
may result from increased fluid intake, present in one-third to one-half of the popula-
decreased levels of antidiuretic hormone, renal tion. They mostly occur in the lower part of the
disease, or the use of drugs (see DIURETICS). COLON, and are predominantly due to muscular
hyperactivity of the bowel forcing the lining of
Diuretics the bowel through weak points in the bowel
Substances which increase urine and solute wall, just as the inner tube of a pneumatic tyre
production by the KIDNEYS. They are used in the bulges through a defective tyre. There is increas-
treatment of heart failure, HYPERTENSION, and ing evidence that the low-residue diet of western
sometimes for ASCITES secondary to liver fail- civilisation is a contributory cause. The condi-
ure. They may work by extra-renal or renal tion may or may not produce symptoms. If it
mechanisms. does, these consist of disturbance of the normal
The potential side-effects of diuretics are bowel function and pain in the left side in the
HYPOKALAEMIA, DEHYDRATION, and GOUT (in
lower abdomen. If diverticulosis is causing
susceptible individuals). symptoms, treatment consists of a high-residue
diet (see CONSTIPATION) and an AGAR or METH-
Extra-renal mechanisms (a) Inhibiting YLCELLULOSE preparation.
release of antidiuretic hormone (e.g. water,
alcohol); (b) increased renal blood flow (e.g. Diverticulum
dopamine in renal doses). A pouch or pocket leading off a main cavity or
tube. The term is especially applied to protru-
Renal mechanisms (a) Osmotic diuretics sions from the intestine, which may be present
act by holding water in the renal tubules and either at the time of birth as a developmental
preventing its reabsorption (e.g. mannitol); (b) peculiarity, or which develop in numbers upon
loop diuretics prevent sodium, and therefore the large intestine during the course of life.
water, reabsorption (e.g. FRUSEMIDE); (c) drugs
acting on the cortical segment of the Loop of Dizygotic Twins
Henle prevent sodium reabsorption, but are Two people born at the same time to the same
weaker than loop diuretics (e.g. THIAZIDES); parents after fertilisation of two separate
 206 Dizziness

ocytes (see OCYTE). They may be of differ- accurate copy of the genetic information of the
ent sexes and are no more likely to resemble parent cells (see GENETIC CODE).
each other than any other sibling pairs.
DNR
Dizziness An acronym for do not resuscitate advice
This means different things to different people, sometimes written on a patients hospital notes
so it is important to establish what the indi- to indicate that if he or she suffers, say, a life-
D vidual means by dizziness. It may encompass a threatening complication (such as a CARDIAC
feeling of disequilibrium; it may be light- ARREST) to an existing serious illness, the
headedness, faintness, a sensation of swimming patient should not be given emergency life-
or floating, an inbalance or unsteadiness, or epi- saving treatment. The use of DNR is an emo-
sodes of mental confusion. It may be true VER- tive and controversial issue, even if the patient
TIGO, which is an hallucination of movement. (or the relatives), when a serious illness such as
These symptoms may be due to diseases of the spreading cancer is concerned, may have indi-
ear, eye, central nervous system, cardiovascular cated a wish not to be resuscitated in the event
system, or endocrine system, or they may be a of organ failures. (See ETHICS.)
manifestation of psychiatric disease. Dizziness is
a common symptom in the elderly and by the Dobutamine
age of 80, two-thirds of women and one-third A cardiac stimulant drug of the inotropic sym-
of men have suffered from the condition. pathomimetic group (see SYMPATHOMIMETIC
DRUGS), dobutamine acts on sympathetic
DLE receptors in cardiac muscle, increasing the con-
See LUPUS Discoid lupus erythematosus tractility and hence improving the cardiac out-
(DLE). put but with little effect on the cardiac rate. It is
particularly useful in cardiogenic shock. It must
DMSA be given by intravenous infusion. (See also
See LEAD POISONING Treatment. HEART.)

DNA Docetaxel
DNA is the abbreviation for deoxyribonucleic A member of the group of antitumour drugs
acid, one of the two types of NUCLEIC ACID that known as TAXANES, docetaxel is used to treat
occur in nature. It is the fundamental genetic advanced or metastatic cancer arising in the
material of all CELLS, and is present in the breast (see BREASTS, DISEASES OF). It is also used
nucleus of the cell where it forms part of the to treat non-small cancer of the LUNGS. The
CHROMOSOMES and acts as the carrier of gen- NATIONAL INSTITUTE FOR CLINICAL EXCEL-
etic information. The molecule is very large, LENCE (NICE) has recommended that both
with a molecular weight of several millions, and docetaxel and PACLITAXEL should be available
consists of two single chains of nucleotides (see for the treatment of advanced breast cancer
NUCLEIC ACID) which are twisted round each where initial anticancer CHEMOTHERAPY
other to form a double helix (or spiral). The (including one of the ANTHRACYCLINES) has
genetic information carried by DNA is encoded failed or is inappropriate.
along one of these strands. A gene, which repre-
sents the genetic information needed to form Doctor
protein, is a stretch of DNA containing, on The academic title granted to someone who has
average, around 1,000 nucleotides paired in a university degree higher than a masters
these two strands (see GENES). degree. Some UK universities grant a medical
To allow it to fulfil its vitally important func- doctorate (MD) for a research thesis of
tion as the carrier of genetic information in liv- approved standard. In Britain, doctor is also
ing cells, DNA has the following properties. It the title given to a qualified medical prac-
is stable, so that successive generations of spe- titioner registered by the General Medical
cies maintain their individual characteristics, Council, usually after he or she has obtained a
but not so stable that evolutionary changes bachelors degree or a diploma in medicine and
cannot take place. It must be able to store a vast surgery. In the UK a doctor has to spend a year
amount of information: for example, an animal of supervised practice in a recognised hospital
cell contains genetic information for the syn- post before he or she is registered as fully quali-
thesis of over a million proteins. It must be fied, but specialists have to obtain further train-
duplicated exactly before each cell division to ing and higher qualifications before they can be
ensure that both daughter cells contain an accredited and therefore practise as specialists in
 Dopamine 207

the NHS. General practitioners must complete living donors. Skin, small pieces of liver, and a
a three-year vocational training course before kidney can, in theory, be obtained from living
practising as an independent GP. In Britain, sur- donors, but the ETHICS of this are hotly debated
gical specialists are customarily addressed as and the situations under which it may be done
Mr. Other countries have different regulations. are tightly controlled. Because transplanted
organs are seen by the receiving body as foreign
Docusate Sodium bodies, careful matching before transplantation
A faecal-softening agent used to treat constipa- is necessary to avoid rejection, and immuno- D
tion in old people. It can be given orally or as a suppressive drugs may be required for some
rectal suppository. time after the operation to prevent this from
occurring.
Dog Bites There are strict regulations about how death
See BITES AND STINGS; RABIES. should be diagnosed before organs can be
removed for transplantation, and potential
Dolichocephalic donors must satisfy the BRAIN-STEM DEATH cri-
Dolichocephalic means long-headed, and is a teria, performed twice by two doctors who are
term applied to skulls the breadth of which is independent of the transplant team. There is a
less than four-fifths of the length. great shortage of suitable organs for donation
partly because they must be in excellent condi-
Dominant Gene tion if the operation is to be a success. Some
See GENETIC DISORDERS. medical conditions or modes of death make
people unsuitable as organ donors; this makes it
Donepezil all the more important that people should be
A drug used for the symptomatic treatment of encouraged to donate their organs. People who
mild to moderate DEMENTIA only in ALZHEIM- wish to do so can carry a special card indicating
ERS DISEASE. Around four in ten patients may their willingness to become donors in the event
benefit by a reduction in the rate of cognitive of their death. These cards can be obtained
and non-cognitive deterioration. from various sources, including hospitals, GPs
surgeries and many public buildings such as
Donor Insemination libraries. In the UK, informed positive approval
Use of the SEMEN of an anonymous donor to from the patient, or relatives, is required.
produce fertilisation in cases of INFERTILITY Information about becoming a blood donor
where the male partner has OLIGOSPERMIA or can be obtained by telephoning 08457 711
IMPOTENCE. The donor is chosen for ethnic 711. Those who wish to bequeath their bodies
and physiognomic similarity to the male part- for dissection purposes should get in touch with
ner and is screened for transmissible diseases HM Inspector of Anatomy. Other would-be
(e.g. HIV, syphilis, hepatitis, gonorrhoea, and organ donors may contact the British Organ
genetic disorders). Insemination is performed at Donor Society.
the time of ovulation by introducing the semen
into the upper vagina. Semen may be fresh or Dopa
have been stored frozen in liquid nitrogen. (See A precursor of DOPAMINE and NORADREN-
ARTIFICIAL INSEMINATION.) ALINE. Levodopa is a drug used in the treatment
of PARKINSONISM. It can cross the bloodbrain
Donors barrier and increase the concentration of
People who donate parts of their bodies for use dopamine in the basal ganglia. It also inhibits
in other people. Many organs and tissues can be prolactin secretion and may be used to treat
donated most commonly blood, but skin, GALACTORRHEA.
corneas, kidneys, livers and hearts can all be
used. Combined heart and lung transplants are Dopamine
being increasingly used for patients with severe Dopamine is one of the CATECHOLAMINES and
lung diseases, and, if the recipients have a con- a precursor of NORADRENALINE. Its highest
dition such as CYSTIC FIBROSIS in which the concentration is in that portion of the brain
heart is normal, it is sometimes possible for known as the basal nuclei (see BRAIN) where its
them to receive a heart and lungs from one function is to convey inhibitory influences to
donor and to donate their own heart to some- the extrapyramidal system. There is good evi-
one else. Recent work has explored the possibil- dence that dopamine deficiency is one of the
ity of using pancreatic transplants. Apart from causative factors in PARKINSONISM.
blood, it is unusual for tissue to be taken from Dopamine is given by intravenous infusion
 208 Dorsal Root Ganglia

as treatment for cardiogenic shock in cardiac as other tissues of the body. In practice, the
infarction or cardiac surgery. question of weight seldom makes much differ-
ence unless the individual is grossly over- or
Dorsal Root Ganglia underweight.
These are swellings on the dorsal roots of spinal
nerves just proximal to the union of the dorsal Idiosyncrasy occasionally causes drugs
and ventral nerve roots. They are situated in the administered in the ordinary dose to produce
inter-vertebral foramina and contain the cell unexpected effects. Thus, some people are but
D little affected by some drugs, whilst in others,
bodies of sensory neurones. (See SPINAL
COLUMN; SPINAL CORD.) certain drugs for example, psychoactive pre-
parations such as sedatives produce excessive
Dorsum symptoms in normal or even small doses. In
(Adjective: dorsal.) The back or posterior part some cases this may be due to hypersensitivity,
of an organ or structure. The dorsum of the or an allergic reaction, to the drug, which is a
hand is the opposite surface to the palm. possibility that must always be borne in mind
(e.g. with PENICILLIN). An individual who is
Dorzolamide known to be allergic to a certain medication is
A carbonic anhydrase-inhibitor drug restricted strongly advised to carry a card to this effect,
to use in patients with raised intraocular pres- and always to inform medical and dental practi-
sure in ocular hypertension or open-angle tioners and/or a pharmacist before accepting a
GLAUCOMA. It can be used alone or as an new prescription or buying an over-the-counter
adjunct to a topical beta blocker (see preparation.
BETA-ADRENOCEPTOR-BLOCKING DRUGS).
Habitual use of a drug is perhaps the influ-
Dosage ence that causes the greatest increase in the dose
Many factors influence the activity with which necessary to produce the requisite effect. The
drugs operate. Among the factors which affect classical example of this is with OPIUM and its
the necessary quantity are age, weight, sex, idio- derivatives.
syncrasy, genetic disorders, habitual use, dis-
Disease may modify the dose of medicines.
ease, fasting, combination with other drugs, the
This can occur in several ways. Thus, in serious
form in which the drug is given, and the route
illnesses the patient may be more susceptible to
by which it is given.
drugs, such as narcotics, that depress tissue
Normally, a young child requires a smaller
activity, and therefore smaller doses must be
dose than an adult. There are, however, other
given. Again, absorption of the drug from the
factors than age to be taken into consideration.
gut may be slowed up by disease of the gut, or
Thus, children are more susceptible than adults
its effect may be enhanced if there is disease of
to some drugs such as MORPHINE, whilst they
the kidneys, interfering with the excretion of
are less sensitive to others such as ATROPINE.
the drug.
The only correct way to calculate a childs dose
is by reference to texts supplying a recom- Fasting aids the rapidity of absorption of
mended dose in milligrams per kilogram. How- drugs, and also makes the body more suscep-
ever, many reference texts simply quote doses tible to their action. Partly for this reason, as
for certain age-ranges. well as to avoid irritation of the stomach, it is
Old people, too, often show an increased usual to prescribe drugs to be taken after meals,
susceptibility to drugs. This is probably due to a and diluted with water.
variety of factors, such as decreased weight;
diminished activity of the tissues and therefore Combination of drugs is to be avoided if
diminished rate at which a drug is utilised; and possible as it is often difficult to assess what
diminished activity of the KIDNEYS resulting in their combined effect may be. In some cases
decreased rate of excretion of the drug. they may have a mutually antagonistic effect,
which means that the patient will not obtain
Weight and sex have both to be taken into full benefit. Sometimes a combination may
consideration. Women require slightly smaller have a deleterious effect.
doses than men, probably because they tend to
be lighter in weight. The effect of weight on Form, route and frequency of admin-
dosage is partly dependent on the fact that istration Drugs are now produced in many
much of the extra weight of a heavy individual forms, though tablets are the most common
is made up of fatty tissue which is not as active and, usually, convenient. In Britain, medicines
 Downs (Down) Syndrome 209

are given by mouth whenever possible, unless analysed after all the data have been collected
there is some degree of urgency, or because the and the code has been broken. Trials should
drug is either destroyed in, or is not absorbed have a separate supervising committee, the
from, the gut. In these circumstances, it is given members of which know the code but do not
intravenously, intra-muscularly or subcutane- take part in the study. Their job is to check the
ously. In some cases, as in cases of ASTHMA or results at intervals so they can stop the trial if
BRONCHITIS, the drug may be given in the form one arm of treatment is clearly better than
of an inhalant (see INHALANTS), in order to get another. Otherwise, it would be unethical to D
the maximum concentration at the point where continue. (See INTERVENTION STUDY.)
it is wanted: that is, in the lungs. If a local effect
is wanted, as in cases of diseases of the skin, the Double Vision
drug is applied topically to the skin. In some See SQUINT.
countries there is a tendency to give medicines
in the form of a suppository which is inserted in Douche
the rectum. An application to the body of a jet of fluid via a
Recent years have seen developments pipe or tube. It may be used to clean any part of
whereby the assimilation of drugs into the body the body but is used most commonly with ref-
can be more carefully controlled. These include, erence to the vagina (although used as a method
for example, what are known as transdermals, in of contraception it is ineffective).
which drugs are built into a plaster that is stuck
on the skin, and the drug is then absorbed into Downs (Down) Syndrome
the body at a controlled rate. This method is A genetic disorder in which the affected person
now being used for the administration of GLYC- usually carries an extra chromosome 47
ERYL TRINITRATE in the treatment of ANGINA instead of the usual 46. The extra chromosome
PECTORIS, and of hyoscine hydrobromide in the occurs in the no. 21 group, hence the disorder is
treatment of MOTION (TRAVEL) SICKNESS. described as trisomy 21. The condition was
Another is a new class of implantable devices. named after Dr J L H Down, the London doc-
These are tiny polymers infused with a drug and tor who first described it in 1866. The incidence
implanted just under the skin by injection. is around one in 600 births. The disorder is
They can be tailored so as to deliver drugs at characterised by a particular physical appear-
virtually any rate from minutes to years. A ance and learning difficulties, with the affected
modification of these polymers now being individuals having an INTELLIGENCE QUOTIENT
investigated is the incorporation of magnetic (IQ) ranging from 30 to 80 (normal is 100).
particles which allow an extra burst of the Most people with the syndrome have eyes that
incorporated drug to be released in response to slope up at the outer corners with skin folds that
an oscillating magnetic field which is induced cover the inner ones. The face and features are
by a magnetic watch worn by the patient. In smaller than normal, while the tongue is larger;
this way the patient can switch on an extra dose the back of the head is flattened and the hands
of drug when this is needed: insulin, for are usually short and broad. The facial features
instance, in the case of diabetics. In yet another led to the syndrome being described as mongol-
new development, a core of drug is enclosed in a ism, a term that is no longer used.
semi-permeable membrane and is released in Children with Downs syndrome are usually
the stomach at a given rate. (See also LIPOSOMES.) friendly and fit in well with the family. Despite
their learning disabilities, some learn to read
Dothiepin and, if they have appropriate educational and
A drug used in the treatment of depression, par- environmental stimulation, can make the most
ticularly when the patient needs sedation. (See of their abilities.
ANTIDEPRESSANT DRUGS.) A heart defect is present in around 25 per
cent of the children at birth, and deafness and
Double Blind Trial acute LEUKAEMIA occur more frequently than in
A scientific study in which different patients unaffected youngsters. Those with the syn-
receive a different drug, the same drug at a dif- drome are particularly prone to developing ear
ferent dose, or a placebo with neither the infections. ATHEROSCLEROSIS often develops
investigators assessing the outcome nor the sub- early in adults and ALZHEIMERS DISEASE tends
jects being treated knowing which of these the to occur as early as 40 years of age. A friendly
latter are receiving. The aim is to remove any home environment helps them to enjoy life, but
hint of bias due to the investigators or patients a few individuals with the syndrome may even-
preferences or preconceptions. The results are tually require institutional care. Improved social
 210 Doxorubicin

and medical care means that many now live (guinea-worm). The major clinical problem is
until their 60s. secondary infection of the worm track, causing
Routine screening tests early in pregnancy, CELLULITIS, SYNOVITIS, epididymo-ORCHITIS,
starting with blood analysis but going on if periarticular FIBROSIS, and ARTHRITIS; TETANUS
necessary to AMNIOCENTESIS and chorionic is a potentially lethal complication. CHEMO-
villus sampling (see PRENATAL SCREENING OR THERAPY is unsatisfactory and the time-
DIAGNOSIS), can identify fetuses likely to honoured method of extracting the female
D develop the disorder. If a sample of fetal cells adult by winding it around a matchstick
confirms the chromosome defect (triple marker remains in use. Surgical treatment may be
test see PREGNANCY AND LABOUR), the parents necessary. Ultimate prevention consists of
may consider termination of the pregnancy. In removing Cyclops spp. from drinking water.
the UK, screening is normally offered to
women over 35 because of their increased risk. Dracunculiasis
When younger parents have a child with See DRACONTIASIS.
Downs syndrome, the chances of a subsequent
child with the disorder are relatively high as it is Dramamine
probable that both parents carry a chromosome See DIMENHYDRINATE.
abnormality insufficient to cause ill-health until
combined. So they may wish to discuss with Draught
their medical advisers the question of further A draught is a small mixture intended to be
pregnancies. taken at one dose. It consists generally of two or
Parents who have a child with Downs syn- four tablespoonfuls of fluid.
drome will understandably feel a combination
of strong emotions, including anger and guilt,
and constructive counselling can be valuable.
Dreams
See SLEEP.
Among societies offering advice and support is
the Downs Syndrome Association.
Drepanocytosis
Doxorubicin Another term for sickle-cell anaemia (see
ANAEMIA), which is characterised by the pres-
A successful and widely used antitumour drug.
It is used in the treatment of acute LEUKAEMIA, ence in the blood of red blood corpuscles that
LYMPHOMA, and various forms of sarcoma
are sickle-like in shape. The anaemia is a severe
and CANCER, including cancer of the bladder. one and afflicts black people and to a lesser
(See CYTOTOXIC.) extent people of Mediterranean background.

Doxycycline Dressings
A wide-spectrum, long-acting antibiotic which See WOUNDS.
is active against a range of micro-organisms,
including the causative organisms of scrub Drop Attack
typhus (see under TYPHUS FEVER), TRACHOMA, A brief episode affecting the nervous system
PSITTACOSIS, LYME DISEASE and some that causes the person to fall suddenly. There is
influenzas. no loss of consciousness. The loss of tone in
the muscles, responsible for the fall, may per-
DPT Vaccine sist for several hours; in such cases moving the
Often called the TRIPLE VACCINE, the injections patient or applying pressure to the soles of the
produce immunity against DIPHTHERIA, feet may restore muscle tone. In most cases,
whooping cough (PERTUSSIS) and TETANUS. however, recovery is immediate. The cause is
The vaccine is given as a course of three injec- probably a temporary interference with the
tions to infants around the ages of two, three blood supply to the brain. In others there may
and four months, together with haemophilus be some disturbance of the vestibular apparatus
influenza B and meningococcal C vaccine as which controls the balance of the body. (See EAR,
well as oral polio vaccine. A booster injection is DISEASES OF; TRANSIENT ISCHAEMIC ATTACKS
given at school entry (see schedule in OR EPISODES (TIA, TIE).)
IMMUNISATION).
Drop Foot
Dracontiasis This is the inability to dorsiflex the foot at the
Dracontiasis, or dracunculiasis, is a nematode ankle. The foot hangs down and has to be
infection caused by Dracunculus medinensis swung clear of the ground while walking. It is
 Drugs 211

commonly caused by damage to the lateral pop- inhibiting its action, potentiating its action, or
liteal nerve or the peroneal muscles. by simple summation of effects.
The interaction may take place:
Drop Wrist (1) Prior to absorption or administration
This is the inability to extend the hand at the for example, antacids bind tetracycline in the
wrist. It is usually due to damage to the radial gut and prevent absorption.
nerve which supplies the extensor muscles. (2) By interfering with protein binding one
drug may displace another from binding sites D
Drowning on plasma proteins. The action of the displaced
See APPENDIX 1: BASIC FIRST AID. drug will be increased because more drug is
now available; for example, anticoagulants are
Drug Absorption displaced by analgesics.
Drugs are usually administered distant to their (3) During metabolism or excretion of the
site of action in the body; they must then pass drug some drugs increase or decrease the
across cell membranes to reach their site of activity of liver enzymes which metabolise
action. For example, drugs given by mouth drugs, thus affecting their rate of destruction;
must pass across the gut membrane to enter the for example, barbiturates, nicotine, and alcohol
bloodstream and then pass through the endo- all activate hepatic enzymes. Altering the pH of
thelium of vessel walls to reach the site of action urine will affect the excretion of drugs via the
in the tissues. This process is called absorption kidney.
and may depend on lipid diffusion, aqueous (4) At the drug receptor one drug may dis-
diffusion, active transport, or pinocytosis a place another at the receptor, affecting its effi-
process in which a cell takes in small droplets of cacy or duration of action.
fluid by cytoplasmic engulfment.
Drug Metabolism
Drug Addiction A process by which the body destroys and
See DEPENDENCE. excretes drugs, so limiting their duration of
action. Phase 1 metabolism consists of trans-
Drug Assisted Rape formation by oxidation, reduction, or
Also known as date rape, this is an unwelcome hydrolysis. In phase 2 this transformed product
phenomenon in which an intending rapist is conjugated (joined up) with another mol-
undermines a potential victims resistance by ecule to produce a water-soluble product which
giving her a hypnotic drug such as benzo- is easier to excrete.
diazepine. The British National Formulary
warns that flunitrazepam (Rohypnol) tablets Drugs
may be particularly subject to abuse perhaps These are natural products or synthetic chem-
given to the unsuspecting victim in an alco- icals that can alter the way in which the body
holic drink so the sedative effect is greatly works, or be used to prevent or treat disease.
enhanced. One or more drugs, combined with stabilisers,
colourings, and other ingredients, make(s) up a
Drug Binding medicine for practical use in treating patients.
The process of attachment of a drug to a recep- (See DEPENDENCE; MEDICINES.) In Britain, the
tor or plasma protein, fat, mucopolysaccharide supply of drugs is controlled by the Medicines
or other tissue component. This process may be Act. Some drugs are available only on prescrip-
reversible or irreversible. tion; some both on prescription and over the
counter; and some are not available on NHS
Drug Clearance prescription. When enquiring about drugs that
The volume of blood from which a drug is a patient is taking, it is essential to ask about all
completely removed in one minute is known as items bought over the counter and any herbal
clearance. Renal clearance of a drug is the or traditional remedies that might be used, as
amount of blood completely cleared of the drug these can interact with other prescribed drugs
by the kidney in one minute. (see DRUG INTERACTIONS) or affect the patients
presenting complaints. Each drug has a single
Drug Interactions generic name, but many will also have several
Many patients are on several prescribed drugs, proprietary (brand) names. It is often much
and numerous medicines are available over the cheaper to prescribe the generic form of a drug,
counter, so the potential for drug interaction is and many doctors do so. Many hospitals and
large. A drug may interact with another by general practices in the United Kingdom now
 212 Drugs in Pregnancy

provide a list of suggested drugs for doctors to development it has reached when the drug is
prescribe. If a doctor wishes to use a drug not given. The stage of early differentiation that
on the list, he or she must give a valid reason. is, from the beginning of the third week to the
Prescriptions for drugs should be printed or end of the tenth week of pregnancy is the time
written clearly in ink and signed and dated by of greatest susceptibility. After this time the risk
the prescriber (computer-generated facsimile of congenital malformation from drug treat-
signatures do not meet legal requirements). ment is less, although the death of the fetus can
D They should include the patients name, occur at any time.
address and age (obligatory for children under
12), the name of the drug to be supplied, the Drunkenness
dose and dose frequency, and the total quantity See ALCOHOL; DEPENDENCE.
to be supplied. Any special instructions (e.g.
after food) should be stated. There are special Duchenne Muscular Dystrophy
regulations about the prescription of drugs con- An X-linked recessive disorder (that is, the
trolled under the Misuse of Drugs Regulations abnormal gene is carried on the X chromo-
1985 (see CONTROLLED DRUGS). A pharmacist some). This means that the disease occurs
can advise about which drugs are available almost exclusively in males, as its presence in a
without prescription, and is able to recommend female is counteracted by the normal gene
treatment for many minor complaints. Infor- likely to be in her other X chromosome. The
mation about exemption from prescription disorder is characterised by progressive muscu-
charges in the NHS can be obtained from lar weakness and wasting. It is the most com-
health visitors, general practitioners, or social mon form of muscular dystrophy, ocurring in
security offices. 30 per 100,000 live male births, often but not
always in families with other members having
Drugs in Pregnancy the disorder.
Unnecessary drugs during pregnancy should be The disease usually appears within the first
avoided because of the adverse effect of some three years of life, beginning in the pelvic girdle
drugs on the fetus which have no harmful effect and lower limbs and later spreading to the
on the mother. Drugs may pass through the shoulder girdle. The calf muscles become bulky
PLACENTA and damage the fetus because their (pseudohypertrophy). The weakness gives rise
pharmacological effects are enhanced as the to a characteristic waddling gait and, when ris-
enzyme systems responsible for their degrad- ing from the supine position, the child rolls on
ation are undeveloped in the fetus. Thus, if the to his face and then uses his arms to push him-
drug can pass through the placenta, the self up. Death usually occurs by the middle of
pharmacological effect on the fetus may be the second decade from respiratory infections.
great whilst that on the mother is minimal. Prenatal screening of female carriers using gene
WARFARIN may thus induce fetal and placental probes is increasingly available. (See DYS-
haemorrhage and the administration of THIAZ- TROPHY; MUSCLES, DISORDERS OF
IDES may produce THROMBOCYTOPENIA in the Myopathy.)
newborn. Many progestogens have androgenic
side-effects and their administration to a Duct
mother for the purpose of preventing recurrent The name applied to a passage leading from a
abortion may produce VIRILISATION of the gland into some hollow organ, or on to the
female fetus. Tetracycline administered during surface of the body, by which the secretion of
the last trimester commonly stains the decidu- the gland is discharged: for example, the pan-
ous teeth of the child yellow. creatic duct and the bile duct opening into the
The other dangers of administering drugs in duodenum, and the sweat ducts opening on the
pregnancy are the teratogenic effects (see TERA- skin surface.
TOGENESIS). It is understandable that a drug
may interfere with a mechanism essential for Ductless Gland
growth and result in arrested or distorted devel- Any one of certain glands in the body the secre-
opment of the fetus and yet cause no disturb- tion of which goes directly into the bloodstream
ance in the adult, in whom these differentiation and so is carried to different parts of the body.
and organisation processes have ceased to be These glands the pituitary, thyroid, para-
relevant. Thus the effect of a drug upon a fetus thyroid, adrenal and reproductive are also
may differ qualitatively as well as quantitatively known as the ENDOCRINE GLANDS. Some
from its effect on the mother. The susceptibility glands may be both duct glands and ductless
of the embryo will depend on the stage of glands. For example, the PANCREAS manu-
 Duodenal Ulcer 213

factures a digestive juice which passes by a common among the upper social classes, and
duct into the small intestine. It also manu- those of blood group O.
factures, by means of special cells, a substance
called INSULIN which passes straight into the Causes It is likely that there is some abrasion,
blood. or break, in the lining membrane (or mucosa)
of the stomach and/or duodenum, and that it
Ductus Arteriosus is gradually eroded and deepened by the acidic
The blood vessel in the fetus through which gastric juice. The bacterium helicobacter pylori D
blood passes from the pulmonary artery to the is present in the antrum of the stomach of
aorta, thereby bypassing the lungs, which do people with peptic ulcers; 15 per cent of
not function during intra-uterine life. (See CIR- people infected with the bacterium develop an
CULATORY SYSTEM OF THE BLOOD.) The ductus ulcer, and the ulcers heal if H. pylori is eradi-
normally ceases to function soon after birth and cated. Thus, this organism has an important
within a few weeks is converted into a fibrous role in creating ulcers. Mental stress may pos-
cord. Occasionally this obliteration does not sibly be a provocative factor. Smoking seems to
occur: a condition known as patent ductus arte- accentuate, if not cause, duodenal ulcer, and
riosus. This is one of the more common con- the drinking of alcohol is probably harmful.
genital defects of the heart, and one which The apparent association with a given blood
responds particularly well to surgical treatment. group, and the fact that relatives of a patient
Closure of the duct can also be achieved in with a peptic ulcer are unduly likely to develop
some cases by the administration of indometh- such an ulcer, suggest that there is some consti-
acin. (See HEART, DISEASES OF.) tutional factor.

Ductus Deferens Symptoms and signs Peptic ulcers may

Ductus deferens, or VAS DEFERENS, is the tube present in different ways, but chronic, episodic
which carries spermatozoa from the epidydimis pain lasting several months or years is most
to the seminal vesicles. (See TESTICLE.) common. Occasionally, however, there may be
an acute episode of bleeding or perforation, or
Dumbness obstruction of the gastric outlet, with little pre-
See SPEECH DISORDERS. vious history. Most commonly there is pain of
varying intensity in the middle or upper right
Dumping Syndrome part of the abdomen. It tends to occur 23
A sensation of weakness and sweating after a hours after a meal, most commonly at night,
meal in patients who have undergone GAS- and is relieved by some food such as a glass of
TRECTOMY. Rapid emptying of the stomach milk; untreated it may last up to an hour.
and the drawing of fluid from the blood into Vomiting is unusual, but there is often tender-
the intestine has been blamed, but the exact ness and stiffness (guarding) of the abdominal
cause is unclear. muscles. Confirmation of the diagnosis is made
by radiological examination (barium meal),
Duodenal Ileus the ulcer appearing as a niche on the film, or by
Dilatation of the DUODENUM due to its chronic looking at the ulcer directly with an endoscope
obstruction, caused by an abnormal position of (see FIBREOPTIC ENDOSCOPY). Chief complica-
arteries in the region of the duodenum pressing tions are perforation of the ulcer, leading to the
on it. vomiting of blood, or HAEMATEMESIS; or less
severe bleeding from the ulcer, the blood pass-
Duodenal Ulcer ing down the gut, resulting in dark, tarry stools
This disorder is related to gastric ulcer (see (see MELAENA).
STOMACH, DISEASES OF), both being a form of
chronic peptic ulcer. Although becoming less Treatment of a perforation involves initial
frequent in western communities, peptic ulcers management of any complications, such as
still affect around 10 per cent of the UK popu- shock, haemorrhage, perforation, or gastric out-
lation at some time. Duodenal ulcers are 1015 let obstruction, usually involving surgery and
times more common than gastric ulcers, and blood replacement. Medical treatment of a
occur in people aged from 20 years onwards. chronic ulcer should include regular meals,
The male to female ratio for duodenal ulcer and the avoidance of fatty foods, strong tea or
varies between 4:1 and 2:1 in different com- coffee and alcohol. Patients should also stop
munities. Social class and blood groups are also smoking and try to reduce the stress in their
influential, with duodenal ulcer being more lives. ANTACIDS may provide symptomatic
 214 Duodenum

relief. However, the mainstay of treatment

involves four- to six-week courses with drugs
intrauterine growth retardation: maternal
disorders; placental abnormalities; multiple
such as CIMETIDINE and RANITIDINE. These are fetuses.
H2 RECEPTOR ANTAGONISTS which heal peptic constitutional delay in normal growth.
ulcers by reducing gastric-acid output. Of those systemic conditions: nutritional deficiencies;
relapsing after stopping this treatment, 6095 gastrointestinal absorption disorders; certain
per cent have infection with H. pylori. A com- chronic diseases; psychosocial deprivation;
D bination of BISMUTH chelate, amoxycillin (see endocrine malfunctions, including HYPO-
PENICILLIN; ANTIBIOTICS) and METRONIDA- THYROIDISM, CUSHINGS SYNDROME, RICK-
ZOLE triple regime should eliminate the ETS, dysfunction of the PITUITARY GLAND
infection: most physicians advise the triple which produces growth hormone, the
regime as first-choice treatment because it is endocrine growth controller.
more likely to eradicate Helicobacter and this, in Treatment of short stature is, where possible,
turn, enhances healing of the ulcer or prevents to remedy the cause: for example, children with
recurrence. Surgery may be necessary if medical hypothyroidism can be given THYROXINE.
measures fail, but its use is much rarer than Children who are not growing properly should
before effective medical treatments were be referred for expert advice to determine the
developed. diagnosis and obtain appropriate curative or
supportive treatments.
Duodenum
The first part of the INTESTINE immediately Dynamometer
beyond the stomach, so-named because its An elliptical ring of steel to which is attached a
length is about 12 fingerbreadths. dial and moving index. It is used to test the
strength of the muscles of the forearm, being
Dupuytrens Contracture squeezed in the hand, and registering the pres-
A condition of unknown aetiology in which sure in pounds or kilograms.
there is progressive thickening and contracture
of the FASCIA in the palm of the hand with Dys-
adherence of the overlying skin. A clawing A prefix meaning difficult or painful.
deformity of the fingers, particularly the little
and ring fingers, develops. It is associated with Dysarthria
liver disease, diabetes, epilepsy, and gout. A general term applied when weakness or
Treatment is surgical to excise the affected incoordination of the speech musculature pre-
fascia. Recurrence is not uncommon. vents clear pronunciation of words. The indi-
viduals speech may sound as if it is slurred or
Dura Mater weak. It may be due to damage affecting the
The outermost and strongest of the three mem- centres in the brain which control movements
branes or meninges which envelop the brain of the speech muscles, or damage to the muscles
and spinal cord. In it run vessels which nourish themselves.
the inner surface of the skull. (See BRAIN.) Examples of dysarthria may be found in
strokes, CEREBRAL PALSY and the latter stages of
DVT PARKINSONISM, MULTIPLE SCLEROSIS (MS) and
See DEEP VEIN THROMBOSIS (DVT). MOTOR NEURONE DISEASE (MND). Whatever
the cause, a speech therapist can assess the
Dwarfism extent of the dysarthria and suggest exercises or
Dwarfism, or short stature, refers to under- an alternative means of communication.
development of the body. The condition,
which has various causes, is not common. All Dyscalculia
children who by the age of five years are at least A condition commonly seen when the brains
what is technically known as three standard PARIETAL LOBE is diseased or injured, in which
deviations below the mean well below aver- an individual finds it hard to carry out simple
age size for children of that age should be mathematical calculations.
referred for specialist advice. Among the causes
are: Dyschezia
genetic: familial; abnormalities of chromo-
somes, for example, TURNERS SYNDROME;
Constipation due to retention of FAECES in the
rectum. This retention is the outcome of irregu-
abnormal skeletal development; and failure lar habits, which damp down the normal reflex
of primary growth. causing defaecation.
 Dyslexia 215

Dysdiadochokinesia entery may be accompanied by weight loss,

Loss of the ability to perform rapid alternate anaemia, and occasionally DYSPNOEA. E. histo-
movements, such as winding up a watch. It is a lytica contaminates food (e.g. uncooked veget-
sign of a lesion in the cerebellum. (See BRAIN.) ables) or drinking water. After ingestion of the
cyst-stage, and following the action of digestive
Dysentery enzymes, the motile trophozoite emerges in the
A clinical state arising from invasive colo-rectal colon causing local invasive disease (amoebic
disease; it is accompanied by abdominal colic, colitis). On entering the portal system, these D
diarrhoea, and passage of blood/mucus in the organisms may gain access to the liver, causing
stool. Although the two major forms are caused invasive hepatic disease (amoebic liver
by Shigella spp. (bacillary dysentery) and Enta- abscess). Other sites of abscess formation
moeba histolytica (amoebic dysentery), other include the lungs (usually right) and brain. In
organisms including entero-haemorrhagic the colo-rectum an amoeboma may be difficult
Escherichia coli (serotypes 0157:H7 and to differentiate from a carcinoma. Clinical
026:H11) and Campylobacter spp. are also rele- symptoms usually occur within a week, but can
vant. Other causes of dysentery include Bal- be delayed for months, or even years; onset may
antidium coli and that caused by schistosomiasis be acute as for Shigella spp. infection. Perfor-
(bilharzia) Schistosoma mansoni and S. japoni- ation, colo-rectal haemorrhage, and appendi-
cum infection. citis are unusual complications. Diagnosis is by
demonstration of E. histolytica trophozoites in a
Shigellosis This form is usually caused by fresh faecal sample; other amoebae affecting
Shigella dysenteriae-1 (Shigas bacillus), Shigella humans do not invade tissues. Research tech-
flexneri, Shigella boydii, and Shigella sonnei; the niques can be used to differentiate between
latter is the most benign and occurs in temper- pathogenic (E. dysenteriae) and non-pathogenic
ate climates also. It is transmitted by food and strains (E. dispar). Alternatively, several sero-
water contamination, by direct contact, and by logical tests are of value in diagnosis, but only in
flies; the organisms thrive in the presence of the presence of invasive disease.
overcrowding and insanitary conditions. The Treatment consists of one of the 5-
incubation is between one and seven days, and nitroimidazole compounds metronidazole,
the severity of the illness depends on the strain tinidazole, and ornidazole; alcohol avoidance is
responsible. Duration of illness varies from a important during their administration. A
few days to two weeks and can be particularly five- to ten-day course should be followed by
severe in young, old, and malnourished indi- diloxanide furoate for ten days. Other com-
viduals. Complications include perforation and pounds emetine, chloroquine, iodoquinol,
haemorrhage from the colo-rectum, the haemo- and paromomycin are now rarely used. Inva-
lytic uraemic syndrome (which includes renal sive disease involving the liver or other organ(s)
failure), and REITERS SYNDROME. Diagnosis is usually responds favourably to a similar regi-
dependent on demonstration of Shigella in (a) men; aspiration of a liver abscess is now rarely
faecal sample(s) before or usually after indicated, as controlled trials have indicated a
culture. similar resolution rate whether this technique
If dehydration is present, this should be is used or not, provided a 5-nitroimidazole
treated accordingly, usually with an oral compound is administered.
rehydration technique. Shigella is eradicated
by antibiotics such as trimethoprim- Dysidrosis
sulphamethoxazole, trimethoprim, ampicillin, Disturbance of sweat secretion.
and amoxycillin. Recently, a widespread resist-
ance to many antibiotics has developed, espe- Dyskinesia
cially in Asia and southern America, where the Abnormal movements of the muscles resulting
agent of choice is now a quinolone compound, from disorder of the brain. Movements are
for example, ciprofloxacin; nalidixic acid is also uncoordinated and involuntary and occur in
effective. Prevention depends on improved facial as well as limb muscles. They include
hygiene and sanitation, careful protection of athetosis (writhing movements), CHOREA (jerk-
food from flies, fly destruction, and garbage ing movements predominate), choreoathetosis
disposal. A Shigella carrier must not be allowed (a combined type), myoclonus (spasms), tics
to handle food. and tremors.

Entamoeba histolytica infection Most Dyslexia

cases occur in the tropics and subtropics. Dys- Dyslexia is difficulty in reading or learning to
 216 Dysmenorrhoea

read. It is always accompanied by difficulty in ficulties in understanding language and in self-

writing, and particularly by difficulties in spell- expression, most frequently after STROKE or
ing. Reading difficulties might be due to vari- other brain damage. When there is a total loss
ous factors for example, a general learning in the ability to communicate through speech
problem, bad teaching or understimulation, or or writing, it is known as global aphasia. Many
a perceptive problem such as poor eyesight. more individuals have a partial understanding
Specific dyslexia (word blindness), however, of what is said to them; they are also able to
D affects 48 per cent of otherwise normal chil- put their own thoughts into words to some
dren to some extent. It is three times more extent. The general term for this less severe
common in boys than in girls, and there is often condition is dysphasia. Individuals vary widely,
a family history. The condition is sometimes but in general there are two main types of
missed and, when a child has difficulty with dysphasia. Some people may have a good
reading, dyslexia should be considered as a pos- understanding of spoken language but have
sible cause. difficulty in self-expression; this is called
Support and advice may be obtained from expressive or motor dysphasia. Others may
the British Dyslexia Association. have a very poor ability to understand speech,
but will have a considerable spoken output
Dysmenorrhoea consisting of jargon words; this is known as
Painful MENSTRUATION. receptive or sensory dysphasia. Similar difficul-
ties may occur with reading, and this is called
Dyspareunia DYSLEXIA (a term more commonly
Dyspareunia means painful or difficult COITUS. encountered in the different context of child-
In women the cause may be physical for rens reading disability). Adults who have suf-
example, due to local inflammation or infection fered a stroke or another form of brain damage
in the vagina or psychological; say, a fear of may also have difficulty in writing, or dys-
intercourse. In men the cause is usually phys- graphia. The speech therapist can assess the
ical, such as prostatitis (see PROSTATE, DISEASES finer diagnostic pointsand help them adjust to
OF) or a tight foreskin (see PREPUCE). the effects of the stroke on communication.
(See SPEECH THERAPY.)
Dyspepsia Dysphasia may come on suddenly and last
This is another name for indigestion. It only for a few hours or days, being due to a
describes a sensation of pain or discomfort in the temporary block in the circulation of blood to
upper abdomen or lower chest following eating. the brain. The effects may be permanent, but
There may be additional symptoms of heart- although the individual may have difficulty in
burn, flatulence, or nausea. There are many understanding language and expressing them-
causes of dyspepsia including oesophagitis (see selves, they will be quite aware of their surround-
OESOPHAGUS, DISEASES OF), PEPTIC ULCER, gall- ings and may be very frustrated by their
stones (see under GALL-BLADDER, DISEASES OF), inability to communicate with others.
HIATUS HERNIA, malignancy of the stomach or Further information may be obtained from
oesophagus, and hepatic or pancreatic disease. Speakability.
Occasionally it may be psychological in origin.
Treatment depends on the underlying cause
but, if there is no specific pathology, avoidance
Dysphonia
Abnormal vocal sounds when speaking. It is
of precipitating foods may be helpful. ANT-
caused by injury or disease of the LARYNX or of
ACIDS may relieve discomfort and pain if taken
the nerves suplying the laryngeal muscles.
when symptoms occur or are expected.

Dysphagia Dysplasia
Difficulty in swallowing. This may be caused by Abnormal development of cells, tissues or struc-
narrowing of the oesophagus because of phys- tures in the body.
ical disease such as cancer or injury. Disturb-
ance to the nervous control of the swallowing Dyspnoea
mechanism for example, in STROKE or Difficulty in breathing (see BREATHLESSNESS;
MOTOR NEURONE DISEASE (MND) can also
ORTHOPNOEA).
cause dysphagia.

Dysphasia Dyspraxia
Dysphasia is the term used to describe the dif- See APRAXIA.
 Dysuria 217

Dysrhythmia with LEVODOPA. Particularly in paediatric prac-

Disturbance in the rhythmical contractions of tice this drug will often be tried on a child with
the heart. It is also called ARRHYTHMIA. dystonia.

Dystocia Dystrophia Myotonica

Slow or painful birth of a child. This may occur A type of muscular dystrophy (see MUSCLES,
because the baby is large and/or the mothers DISORDERS OF) in which the affected person
pelvis is small or wrongly shaped for the baby to has weakness and wasting of the muscles, par- D
pass through easily. Abnormal presentation of ticularly those in the face and neck. Other
the baby is another cause (see PREGNANCY AND effects are CATARACT, ptosis (see EYE, DISORDERS
LABOUR; BREECH PRESENTATION). OF), baldness and malfunctioning of the endo-
crine system (see ENDOCRINE GLANDS). Both
Dystonia sexes may be affected by this inherited disorder.
Dystonia refers to a type of involuntary
movement characterised by a sustained muscle Dystrophy
contraction, frequently causing twisting and Dystrophy means defective or faulty nutrition,
repetitive movements or abnormal postures, and is a term applied to a group of develop-
and caused by inappropriate instructions from mental changes occurring in the muscles,
the brain. It is sometimes called torsion independently of the nervous system (see
spasm, and may be synonymous with MUSCLES, DISORDERS OF). The best-known
ATHETOSIS when the extremities are involved. form is progressive muscular dystrophy, a group
Often the condition is of unknown cause of hereditary disorders characterised by sym-
(idiopathic), but an inherited predisposition is metrical wasting and weakness, with no sensory
increasingly recognised among some cases. loss. There are three types: Duchenne (usually
Others may be associated with known path- occurring in boys within the first three years of
ology of the brain such as CEREBRAL PALSY or life); limb girdle (occurring in either sex in the
WILSONS DISEASE. second or third decade); and facio-scapulo-
The presentation of dystonia may be focal humeral (either sex, any age). The three types
(usually in adults) causing blepharospasm have different prognoses, but may lead to severe
(forceful eye closure), oromandibular dystonia disability and premature death, often from
(spasms of the tongue and jaw), cranial dysto- respiratory failure. The third type progresses
nia/Meige syndrome/Brueghels syndrome very slowly, however, and is compatible with a
(eyes and jaw both involved), spastic or spas- long life.
modic dysphonia/laryngeal dystonia (strained Diagnosis may be confirmed by ELECTRO-
or whispering speech), spasmodic dysphagia MYOGRAPHY (EMG) or muscle biopsy. Although
(difficulty swallowing), spasmodic torti/latero/ genetic research is pointing to possible treat-
ante/retrocollis (rotation, sideways, forward or ment or prevention, at present no effective
backward tilting of the neck), dystonic writers treatment is known, and deterioration may
cramp or axial dystonia (spasms deviating the occur with excessive confinement to bed.
torso). Foot dystonia occurs almost exclusively Physio-therapeutic and orthopaedic measures
in children and adolescents. In adults, the con- may be necessary to counteract deformities and
dition usually remains focal or involves at most contractures, and may help in coping with
an adjacent body part. In children, it may some disabilities.
spread to become generalised. The condition
has always been considered rare, but commonly Dysuria
is either not diagnosed or mistakenly thought Difficulty or pain in urination. The condition is
to be of psychological origin. It may, in fact, be commonly associated with frequency and
half as common as MULTIPLE SCLEROSIS (MS). urgency of MICTURITION if caused by infection
Similar features can occur in some subjects of the bladder (CYSTITIS) or urethra (see
treated with major tranquillising drugs, in URETHRA, DISEASES OF). A burning feeling is
whom a predisposition to develop dystonia may common and relief is achieved by treating the
be present. underlying cause. Drinking large amounts of
One rare form, called dopa-responsive dys- water may help to alleviate symptoms. If these
tonia, can be largely abolished by treatment persist, medical advice should be sought.
 ments which can affect the fluid in the inner

E ear.
The middle ear has two connections which
are of great importance as regards disease (see
EAR, DISEASES OF). In front, it communicates by
a passage 37 mm (1.5 inches) long the Eus-
tachian (or auditory) tube with the upper part
Ear of the throat, behind the nose; behind and
The ear is concerned with two functions. The above, it opens into a cavity known as the mas-
more evident is that of the sense of hearing; the toid antrum. The Eustachian tube admits air
other is the sense of equilibration and of from the throat, and so keeps the pressure on
motion. The organ is divided into three parts: both sides of the drum fairly equal.
(1) the external ear, consisting of the auricle on
the surface of the head, and the tube which Internal ear This consists of a complex sys-
leads inwards to the drum; (2) the middle ear, tem of hollows in the substance of the temporal
separated from the former by the tympanic bone enclosing a membranous duplicate.
membrane or drum, and from the internal ear Between the membrane and the bone is a fluid
by two other membranes, but communicating known as perilymph, while the membrane is
with the throat by the Eustachian tube; and (3) distended by another collection of fluid known
the internal ear, comprising the complicated as endolymph. This membranous labyrinth, as
labyrinth from which runs the vestibulococh- it is called, consists of two parts. The hinder
lear nerve into the brain. part, comprising a sac (the utricle) and three
short semicircular canals opening at each end
External ear The auricle or pinna consists into it, is the part concerned with the balancing
of a framework of elastic cartilage covered by sense; the forward part consists of another small
skin, the lobule at the lower end being a small bag (the saccule), and of a still more important
mass of fat. From the bottom of the concha the part, the cochlear duct, and is the part con-
external auditory (or acoustic) meatus runs cerned with hearing. In the cochlear duct is
inwards for 25 mm (1 inch), to end blindly at placed the spiral organ of Corti, on which
the drum. The outer half of the passage is sound-waves are finally received and by which
surrounded by cartilage, lined by skin, on the sounds are communicated to the cochlear
which are placed fine hairs pointing outwards, nerve, a branch of the vestibulocochlear nerve,
and glands secreting a small amount of wax. which ends in filaments to this organ of
In the inner half, the skin is smooth and lies Corti. The essential parts in the organ of
directly upon the temporal bone, in the sub- Corti are a double row of rods and several
stance of which the whole hearing apparatus is rows of cells furnished with fine hairs of vary-
enclosed. ing length which respond to differing sound
frequencies.
Middle ear The tympanic membrane, form-
ing the drum, is stretched completely across the The act of hearing When sound-waves in
end of the passage. It is about 8 mm (one-third the air reach the ear, the drum is alternately
of an inch) across, very thin, and white or pale pressed in and pulled out, in consequence of
pink in colour, so that it is partly transparent which a to-and-fro movement is communicated
and some of the contents of the middle ear to the chain of ossicles. The foot of the stapes
shine through it. The cavity of the middle ear is communicates these movements to the peri-
about 8 mm (one-third of an inch) wide and 4 lymph. Finally these motions reach the delicate
mm (one-sixth of an inch) in depth from the filaments placed in the organ of Corti, and so
tympanic membrane to the inner wall of bone. affect the auditory nerve, which conveys
Its important contents are three small bones impressions to the centre in the brain.
the malleus (hammer), incus (anvil) and stapes
(stirrup) collectively known as the auditory Ear, Diseases of
ossicles, with two minute muscles which regu- Diseases may affect the EAR alone or as part of a
late their movements, and the chorda tympani more generalised condition. The disease may
nerve which runs across the cavity. These three affect the outer, middle or inner ear or a com-
bones form a chain across the middle ear, con- bination of these.
necting the drum with the internal ear. Their
function is to convert the air-waves, which Examination of the ear includes inspection
strike upon the drum, into mechanical move- of the external ear. An auriscope is used to
 Ear, Diseases of 219

Auriscope positioned in external auditory meatus of left ear for viewing ear drum.

examine the external ear canal and the ear General symptoms The following are some
drum. If a more detailed inspection is required, of the chief symptoms of ear disease:
a microscope may be used to improve illumin- DEAFNESS (see DEAFNESS).
ation and magnification. EARACHE is most commonly due to acute
inflammation of the middle ear. Perceived pain
Tuning-fork or Rinne tests are per- in this region may be referred from other areas,
formed to identify the presence of DEAFNESS. such as the earache commonly experienced after
The examiner tests whether the vibrating fork is tonsillectomy (removal of the TONSILS) or that
audible at the meatus, and then the foot of the caused by carious teeth (see TEETH, DISORDERS
fork is placed on the mastoid bone of the ear to OF). The treatment will depend on the under-
discover at which of the two sites the patient lying cause.
can hear the vibrations for the longest time. TINNITUS or ringing in the ear often accompan-
This can help to differentiate between conduct- ies deafness, but is sometimes the only symp-
ive and nerve deafness. tom of ear disease. Even normal people some-
times experience tinnitus, particularly if put in
Hearing tests are carried out to determine soundproofed surroundings. It may be
the level of hearing. An audiometer is used to described as hissing, buzzing, the sound of the
deliver a series of short tones of varying fre- sea, or of bells. The intensity of the tinnitis usu-
quency to the ear, either through a pair of ally fluctuates, sometimes disappearing
headphones or via a sound transducer applied altogether. It may occur in almost any form of
directly to the skull. The intensity of the sound ear disease, but is particularly troublesome in
is gradually reduced until it is no longer heard nerve deafness due to ageing and in noise-
and this represents the threshold of hearing, at induced deafness.
that frequency, through air and bone respect- The symptom seems to originate in the
ively. It may be necessary to play a masking brains subcortical regions, high in the central
noise into the opposite ear to prevent that ear nervous system. It may be a symptom of general
from hearing the tones, enabling each ear to be diseases such as ANAEMIA, high blood pressure
tested independently. and arterial disease, in which cases it is often
 220 Ear, Diseases of

synchronous with the pulse, and may also be CHRONIC OTITIS EXTERNA producing pain and
caused by drugs such as QUININE, salicylates discharge, can be caused by eczema, seborrhoeic
(SALICYLIC ACID and its salts, for example, DERMATITIS or PSORIASIS. Hair lotions and
ASPIRIN) and certain ANTIBIOTICS. Treatment of cosmetic preparations may trigger local allergic
any underlying ear disorder or systemic disease, reactions in the external ear, and the chronic
including DEPRESSION, may reduce or even cure disorder may be the result of swimming or use
the tinnitis, but unfortunately in many cases of dirty towels. Careful cleaning of the ear by an
the noises persist. Management involves psy- ENT (Ear, Nose & Throat) surgeon and topical
chological techniques and initially an explan- antibiotic or antifungal agents along with
ation of the mechanism and reassurance that removal of any precipitating cause are the
E tinnitus does not signify brain disease, or an usual treatments.
impending STROKE, may help the person. Tin- TUMOURS of the ear can arise in the skin of the
nitus maskers which look like hearing aids auricle, often as a result of exposure to sunlight,
have long been used with a suitably pitched and can be benign or malignant. Within the ear
sound helping to mask the condition. canal itself, the commonest tumours are benign
outgrowths from the surrounding bone, said to
Diseases of the external ear occur in swimmers as a result of repeated
WAX (cerumen) is produced by specialised exposure to cold water. Polyps may result from
glands in the outer part of the ear canal only. chronic infection of the ear canal and drum,
Impacted wax within the ear canal can cause particularly in the presence of a perforation.
deafness, tinnitis and sometimes disturbance of These polyps are soft and may be large enough
balance. Wax can sometimes be softened with to fill the ear canal, but may shrink considerably
olive oil, 5-per-cent bicarbonate of soda or after treatment of the associated infection.
commercially prepared drops, and it will grad-
ually liquefy and remove itself. If this is inef- Diseases of the middle ear
fective, syringing by a doctor or nurse will usu- OTITIS MEDIA or infection of the middle ear,
ally remove the wax but sometimes it is neces- usually occurs as a result of infection spreading
sary for a specialist (otologist) to remove it up the Eustachian tubes from the nose, throat
manually with instruments. Syringing should or sinuses. It may follow a cold, tonsillitis or
not be done if perforation of the tympanic sinusitis, and may also be caused by swimming
membrane (eardrum) is suspected. and diving where water and infected secretions
FOREIGN BODIES such as peas, beads or buttons are forced up the Eustachian tube into the mid-
may be found in the external ear canal, espe- dle ear. Primarily it is a disease of children, with
cially in children who have usually introduced as many as 1.5 million cases occurring in Brit-
them themselves. Live insects may also be ain every year. Pain may be intense and throb-
trapped in the external canal causing intense bing or sharp in character. The condition is
irritation and noise, and in such cases spirit accompanied by deafness, fever and often
drops are first instilled into the ear to kill the TINNITUS.
insect. Except in foreign bodies of vegetable In infants, crying may be the only sign that
origin, where swelling and pain may occur, syr- something is wrong though this is usually
inging may be used to remove some foreign accompanied by some localising manifestation
bodies, but often removal by a specialist using such as rubbing or pulling at the ear. Examin-
suitable instrumentation and an operating ation of the ear usually reveals redness, and
microscope is required. In children, a general sometimes bulging, of the ear drum. In the
anaesthetic may be needed. early stages there is no discharge, but in the later
ACUTE OTITIS EXTERNA may be a diffuse stages there may be a discharge from perfor-
inflammation or a boil (furuncle) occurring in ation of the ear drum as a result of the pressure
the outer ear canal. The pinna is usually tender created in the middle ear by the accumulated
on movement (unlike acute otitis media see pus. This is usually accompanied by an
below) and a discharge may be present. Initially immediate reduction in pain.
treatment should be local, using magnesium Treatment consists of the immediate
sulphate paste or glycerine and 10-per-cent ich- administration of an antibiotic, usually one of
thaminol. Topical antibiotic drops can be used the penicillins (e.g. amoxicillin). In the major-
and sometimes antibiotics by mouth are neces- ity of cases no further treatment is required, but
sary, especially if infection is acute. Clotrima- if this does not quickly bring relief then it may
zole drops are a useful antifungal treatment. be necessary to perform a myringotomy, or
Analgesics and locally applied warmth should incision of the ear drum, to drain pus from the
relieve the pain. middle ear. When otitis media is treated
 Eating Disorders 221

immediately with sufficient dosage of the rest and drugs to control sickness. Vasodilator
appropriate antibiotic, the chances of any per- drugs such as betahistine hydrochloride may be
manent damage to the ear or to hearing are helpful. Surgical treatment is sometimes
reduced to a negligible degree, as is the risk of required if crippling attacks of dizziness persist
any complications such as mastoiditis (dis- despite these measures.
cussed later in this section). OTOSCLEROSIS A disorder of the middle ear
CHRONIC OTITIS MEDIA WITH EFFUSION or that results in progressive deafness. Often run-
glue ear, is the most common inflammatory ning in families, otosclerosis affects about one
condition of the middle ear in children, to the person in 200; it customarily occurs early in
extent that one in four children in the UK adult life. An overgrowth of bone fixes the
entering school has had an episode of glue ear. stapes (the innermost bone of the middle ear) E
It is characterised by a persistent sticky fluid in and stops sound vibrations from being trans-
the middle ear (hence the name); this causes a mitted to the inner ear. The result is conduct-
conductive-type deafness. It may be associated ive deafness. The disorder usually affects both
with enlarged adenoids (see NOSE, DISORDERS ears. Those affected tend to talk quietly and
OF) which impair the function of the Eus- deafness increases over a 1015 year period.
tachian tube. If the hearing impairment is per- Tinnitus often occurs, and occasionally vertigo.
sistent and causes problems, drainage of the Abnormal hearing tests point to the diag-
fluid, along with antibiotic treatment, may be nosis; the deafness may be partially overcome
needed possibly in conjunction with removal of with a hearing aid but surgery is eventually
the adenoids. The insertion of grommets (venti- needed. This involves replacing the stapes bone
lation tubes) was for a time standard treatment, with a synthetic substitute (stapedectomy). (See
but while hearing is often restored, there may also OTIC BAROTRAUMA.)
be no long-term gain and even a risk of damage
to the tympanic membrane, so the operation is Eating Disorders
less popular than it was a decade or so ago. The term eating disorders covers OBESITY,
MASTOIDITIS is a serious complication of feeding problems in childhood, anorexia ner-
inflammation of the middle ear, the incidence vosa, and bulimia nervosa. The latter two are
of which has been dramatically reduced by the described here.
introduction of antibiotics. Inflammation in
this cavity usually arises by direct spread of Anorexia nervosa Often called the
acute or chronic inflammation from the middle slimmers disease, this is a syndrome charac-
ear. The signs of this condition include swelling terised by the loss of at least a quarter of a
and tenderness of the skin behind the ear, red- persons normal body weight; by fear of nor-
ness and swelling inside the ear, pain in the side mal weight; and, in women, by AMENOR-
of the head, high fever, and a discharge from the RHOEA. An individuals body image may be
ear. The management of this condition in the distorted so that the sufferer cannot judge real
first instance is with antibiotics, usually given weight and wants to diet even when already
intravenously; however, if the condition fails to very thin.
improve, surgical treatment is necessary. This Anorexia nervosa usually begins in ado-
involves draining any pus from the middle ear lescence, affecting about 12 per cent of teen-
and mastoid, and removing diseased lining and agers and college students at any time. It is 20
bone from the mastoid. times more common among women than men.
Up to 10 per cent of sufferers sisters also have
Diseases of the inner ear the syndrome. Anorexia may be linked with
MENIRES DISEASE is a common idiopathic episodes of bulimia (see below).
disorder of ENDOLYMPH control in the semi- The symptoms result from secretive self-
circular canals (see EAR), characterised by the starvation, usually with excessive exercise, self-
triad of episodic VERTIGO with deafness and induced vomiting, and misuse of laxatives. An
tinnitus. The cause is unknown and usually one anorexic (or anorectic) person may wear layers
ear only is affected at first, but eventually the of baggy clothes to keep warm and to hide the
opposite ear is affected in approximately 50 per figure. Starvation can cause serious problems
cent of cases. The onset of dizziness is often such as ANAEMIA, low blood pressure, slow
sudden and lasts for up to 24 hours. The hear- heart rate, swollen ankles, and osteoporosis.
ing loss is temporary in the early stages, but Sudden death from heart ARRHYTHMIA may
with each attack there may be a progressive occur, particularly if the sufferer misuses
nerve deafness. Nausea and vomiting often DIURETICS to lose weight and also depletes the
occur. Treatment during the attacks includes bodys level of potassium.
 222 Ebola Virus Disease

There is probably no single cause of anorexia much more common. In one survey of female
nervosa. Social pressure to be thin seems to be college students, 13 per cent admitted to having
an important factor and has increased over the had bulimic symptoms.
past 2030 years, along with the incidence of Bulimia nervosa rarely leads to serious phys-
the syndrome. Psychological theories include ical illness or death. However, repeated vomit-
fear of adulthood and fear of losing parents ing can cause oesophageal burns, salivary gland
attention. infections, small tears in the stomach, and
Treatment should start with the general prac- occasionally dehydration and chemical imbal-
titioner who should first rule out other illnesses ances in the blood. Inducing vomiting using
causing similar signs and symptoms. These fingers may produce two tell-tale signs bite
E include DEPRESSION and disorders of the bowel, marks on the knuckles and rotten, pitted teeth.
PITUITARY GLAND, THYROID GLAND, and Those suffering from this condition may
OVARIES. obtain advice from the Eating Disorders
If the diagnosis is clearly anorexia nervosa, Association.
the general practitioner may refer the sufferer to
a psychiatrist or psychologist. Moderately ill Ebola Virus Disease
sufferers can be treated by COGNITIVE Ebola virus disease is another name for VIRAL
BEHAVIOUR THERAPY. A simple form of this is HAEMORRHAGIC FEVER. The ebola virus is one
to agree targets for daily calorie intake and for of the most virulent micro-organisms known.
acceptable body weight. The sufferer and the Like the marburg virus (see MARBURG DIS-
therapist (the general practitioner or a member EASE), it belongs to the filovirus group which
of the psychiatric team) then monitor progress originates in Africa. Increased population
towards both targets by keeping a diary of food mobility and wars have meant that the infec-
intake and measuring weight regularly. Coun- tion occasionally occurs elsewhere, with air
selling or more intensely personal PSYCHO- travellers developing symptoms on returning
THERAPY may help too. Severe life-threatening home.
complications will need urgent medical treat-
ment in hospital, including rehydration and Treatment As the disease can be neither pre-
feeding using a nasogastric tube or an intraven- vented nor cured, treatment is supportive, with
ous drip. strict anti-infection procedures essential as
About half of anorectic sufferers recover fully human-to-human transmission can occur via
within four years, a quarter improve, and a skin and mucous-membrane contacts. Incuba-
quarter remain severely underweight with (in tion period is 510 days. Fever with MYALGIA
the case of women) menstrual abnormalities. and headache occur initially, often accom-
Recovery after ten years is rare and about 3 per panied by abdominal and chest symptoms.
cent die within that period, half of them by Haemorrhagic symptoms soon develop and the
suicide. victim either starts to improve in the second
week or develops multi-organ failure and lapses
Bulimia nervosa is a syndrome character- into a coma. Mortality ranges from 25 to 90 per
ised by binge eating, self-induced vomiting and cent.
laxative misuse, and fear of fatness. There is
some overlap between anorexia nervosa and Eburnation
bulimia but, unlike the former, bulimia may Eburnation is a process of hardening and pol-
start at any age from adolescence to 40 and is ishing which takes place at the ends of bones,
probably more directly linked with ordinary giving them an ivory-like appearance. It is
dieting. Bulimic sufferers say that, although caused by the wearing away, in consequence
they feel depressed and guilty after binges, the of OSTEOARTHRITIS, of the smooth plates of
buzz and relief after vomiting and purging are cartilage which in health cover the ends of the
addictive. They often respond well to cognitive bones.
behaviour therapy.
Bulimia nervosa does not necessarily cause Ecchymosis
weight loss because the binges for example of The development of a discoloured skin patch
a loaf of bread, a packet of cereal, and several resulting from escape of blood into the tissues
cans of cold baked beans at one sitting are just under the skin, often from bruising.
cancelled out by purging, by self-induced
vomiting and by brief episodes of starvation. ECG
The full syndrome has been found in about 1 See ELECTROCARDIOGRAM (ECG).
per cent of women but mild forms may be
 Ecstasy 223

Echinococcus Symptoms Warning symptoms include diz-

The immature form of a small tapeworm, Tae- ziness, headache, oedema, vomiting, and the
nia echinococcus, found in dogs, wolves and secretion of albumin (protein) in the urine.
jackals and from which human beings become These are normally accompanied by a rise in
infected, so that they harbour the immature blood pressure, which can be severe. Pre-
parasite in the form known as hydatid cyst. (See eclamptic symptoms may be present for some
TAENIASIS.) days or weeks before the seizure takes place,
and, if a woman is found to have these during
Echocardiography antenatal care, preventive measures must be
The use of ultrasonics (see ULTRASOUND) for taken. Untreated, CONVULSIONS and
unconsciousness are very likely, with serious E
the purpose of examining the HEART. By thus
recording the echo (hence the name) from the migraine-like frontal headache and epigastric
heart of ultrasound waves, it is possible to pain the symptoms.
study, for example, the movements of the
heart valves as well as the state of the interior Treatment Prevention of eclampsia by deal-
of the heart. Safe, reliable and painless, the ing with pre-eclamptic symptoms is the best
procedure cuts the need for the physically management, but even this may not prevent
interventionist procedure of CARDIAC
convulsions. Hospital treatment is essential if
CATHETERISATION.
eclampsia develops, preferably in a specialist
unit. The treatment of the seizures is that gen-
erally applicable to convulsions of any kind,
Echolalia with appropriate sedatives given such as intra-
Echolalia is the meaningless repetition, by a venous DIAZEPAM. HYDRALLAZINE intravenously
person suffering from mental deterioration, of should also be administered to reduce the blood
words and phrases addressed to him/her. pressure. Magnesium sulphate given intramus-
cularly sometimes helps to control the fits. The
Echoviruses babys condition should be monitored
Echoviruses, of which there are more than 30 throughout.
known types, occur in all parts of the world. Urgent delivery of the baby, if necessary by
Their full name is Enteric Cytopathogenic CAESAREAN SECTION, is the most effective
Human Orphan (ECHO hence the acronym). treatment for a mother with acute eclampsia.
They are more common in children than in (See PREGNANCY AND LABOUR.)
adults, and have been responsible for outbreaks Women who have suffered from eclampsia
of MENINGITIS, common-cold-like illnesses, are liable to suffer a recurrence in a further
gastrointestinal infections, and infections of the preganancy. Careful monitoring is required.
respiratory tract. They are particularly danger- There is a self-help organisation, Action on
ous when they infect premature infants, and Pre-eclampsia (APEC), to advise on the
there have been several outbreaks of such infec- condition.
tion in neonatal units, in which premature
infants and other seriously ill small babies are Ecstasy
nursed. The virus is introduced to such units by Ecstasy refers to a morbid mental condition,
mothers, staff and visitors who are unaware that associated with an extreme sense of well-
they are carriers of the virus. being, with a feeling of rapture, and tempor-
ary loss of self-control. It often presents as a
Eclampsia form of religious obsession, with a feeling of
A rare disorder in which convulsions occur direct communication with God, saintly
during late pregnancy (see also PREGNANCY voices and images being perceived. In milder
AND LABOUR Increased blood pressure). cases the patient may preach as though with a
This condition occurs in around 50 out of divine mission to help others. Ecstasy may
every 100,000 pregnant women, especially in occur in happiness PSYCHOSIS, SCHIZO-
the later months and at the time of delivery, PHRENIA, certain forms of EPILEPSY, and
but in a few cases only after delivery has taken abnormal personalities.
place. The cause is not known, although cere- The term is also a street drug name for an
bral OEDEMA is thought to occur. In practic- amphetamine derivative, 3, 4-methylene-
ally all cases the KIDNEYS are profoundly dioxymethamphetamine or MDMA, increas-
affected. Effective antenatal care should iden- ingly used as a recreational drug. It is classified
tify most women at risk of developing as a class A drug under the Misuse of Drugs Act
eclampsia. 1971. MDMA is structurally similar to
 224 ECT

endogenous CATECHOLAMINES and produces Ectopic

central and peripheral sympathetic stimulation Ectopic means out of the usual place. For
of alpha and beta ADRENERGIC RECEPTORS. It is example, the congenital displacement of the
taken into nerve terminals by the serotonin heart outside the thoracic cavity is said to be
transporter and causes release of the NEURO- ectopic. An ectopic gestation means a preg-
TRANSMITTER substances serotonin and dopa- nancy outside of the womb (see ECTOPIC
mine. Following this, SEROTONIN depletion is PREGNANCY).
prolonged. As serotonin plays a major part in
mood control, this leads to the characteristic Ectopic Beat
midweek depression experienced by MDMA A heart muscle contraction that is outside the
E users. normal sequence of the cardiac cycle (see
Several fatalities in young people have been HEART). The impulse is generated outside the
attributed to adverse reactions resulting from usual focus of the SINOATRIAL NODE. Also
MDMA use/abuse and possibly accompanying known as extrasystoles, ectopic beats are called
alcohol consumption. The principal effects are ventricular if they arise from a focus in the
increase in pulse, blood pressure, temperature ventricles and supraventricular if they arise
and respiratory rate. Additional complications in the atria. They may cause no symptoms and
such as cardiac ARRHYTHMIA, heatstroke-type the affected subject may be unaware of them.
syndrome, HYPONATRAEMIA and brain haemor- The beat may, however, be the result of heart
rhage may occur. There is also concern over disease or may be caused by NICOTINE or CAF-
possible effects on the mental concentration FEINE. If persistent, the individual may suffer
and memory of those using ecstasy. from irregular rhythm or ventricular fibrillation
Management of patients who get to hospital and need treatment with anti-arrhythmic drugs.
is largely symptomatic and supportive but may
include gastric decontamination, and use of Ectopic Pregnancy
DIAZEPAM as the first line of treatment as it An ectopic pregnancy most commonly develops
reduces central stimulation which may also in one of the FALLOPIAN TUBES. Occasionally it
reduce TACHYCARDIA, HYPERTENSION and may occur in one of the OVARIES, and rarely in
PYREXIA. the uterine cervix or the abdominal cavity.
Around one in 200 pregnant women have an
ECT ectopic gestation. As pregnancy proceeds, sur-
See ELECTROCONVULSIVE THERAPY (ECT). rounding tissues may be damaged and, if ser-
ious bleeding happens, the woman may present
Ectasia as an abdominal emergency. A life-threatening
A term that means widening, usually referring condition, this needs urgent surgery. Most
to a disorder of a duct bearing secretions from a women recover satisfactorily and can have fur-
gland or organ (e.g. mammary duct ectasia). ther pregnancies despite the removal of one Fal-
lopian tube as a result of the ectopic gestation.
Death is unusual. This disorder of pregnancy
Ecthyma may occur because infection or a previous
In debilitated or immunodepressed subjects, abdominal injury or operation may have dam-
staphylococcal IMPETIGO or folliculitis aged the normal descent of an ovum from the
(inflammation of hair follicles [see SKIN]) may ovary to the womb. The first symptoms usually
become ulcerated. This is called ecthyma and is appear during the first two months of preg-
seen in vagrants, drug addicts, and individuals nancy, perhaps before the woman realises she is
with AIDS/HIV or uncontrolled DIABETES pregnant. Severe lower abdominal pain and
MELLITUS.
vaginal bleeding are common presenting symp-
toms. Ultrasound can be used to diagnose the
Ecto- condition and laparoscopy can be used to
Ecto- is a prefix meaning on the outside. remove the products of conception. (See
PREGNANCY AND LABOUR.)
Ectoderm
The outer of the three germ layers of the Ectromelia
EMBRYO during its early development. The Ectromelia means the absence of a limb or
ectoderm develops into the nervous systems, limbs, from congenital causes.
organs of sensation, teeth and lining of mouth,
and the SKIN and its associated structures such Ectropion
as hair and nails. See EYE, DISORDERS OF.
 Electrical Injuries 225

Eczema Egg
See DERMATITIS. See OVUM.

Edentulous Ego
Lacking teeth: this may be because teeth have A psychoanalytical term to describe that part of
not developed or because they have been the mind which develops as a result of the indi-
removed or fallen out. viduals interactions with the outside world.
Freud (see FREUDIAN THEORY) describes the Ego
EDTA as reconciling the demands of the Id (a persons
Ethylenediamine tetra-acetic acid is used to unconscious, instinctive mind), the Superego
treat poisoning with metals such as lead and (moral conscience) and the reality of the out-
E
strontium. One of the CHELATING AGENTS, side world.
EDTA is used in the form of sodium or cal-
cium salts. The stable chelate compounds Eisenmenger Syndrome
resulting from the treatment are excreted in the A condition in which the subject suffers from
urine. a defect in one of the dividing walls (septum)
of the HEART and this is accompanied by
EEG PULMONARY HYPERTENSION. The defect
See ELECTROENCEPHALOGRAPHY (EEG). allows blood low in oxygen to flow from the
right to the left side of the heart and be
Efavirenz pumped into the aorta, which normally carries
A drug known as a non-nucleoside reverse tran- oxygenated blood to the body. The patient has
scriptase inhibitor, used in the treatment of a dusky blue appearance, becomes breathless
HIV infection in combination with other and has a severely restricted exercise tolerance.
antiretroviral drugs (see VIRUSES; AIDS/HIV). It There is an increase in red blood cells as the
should not be used in patients with severe body attempts to compensate for the lowered
kidney impairment or liver damage. Pregnant oxygen delivery. The condition may be
women and older people should not take avoided by early surgical repair of the septal
efavirenz. The drug has a wide range of defect, but once it is evident, surgery may not
side-effects. be possible.

Efferent Ejaculation
The term applied to vessels which convey away The expulsion of SEMEN from the PENIS during
blood or a secretion from a body part, or to ORGASM. The stimulation of sexual intercourse
nerves which carry nerve impulses outwards (coitus) or masturbation produces a spinal
from the nerve-centres. (Opposite: AFFERENT.) reflex action that causes ejaculation. As well as
containing spermatozoa (male germ cells), the
Effort Syndrome semen comprises several constituents arising
Also known as Da Costas syndrome, this is a from COWPERS GLANDS, the PROSTATE GLAND,
condition in which symptoms occur, such as the testicles and seminal vesicles (see TESTICLES)
palpitations and shortness of breath, which are and these are discharged in sequence. (See also
attributed by the patient to disorder of the PREMATURE EJACULATION.)
heart. There is no evidence, however, of heart
disease, and psychological factors are thought to Elastic Tissue
be of importance. (See PSYCHOSOMATIC CONNECTIVE TISSUE which contains a profu-
DISEASES.) sion of yellow elastic fibres. Long, slender and
branching, these fibres (made up of elastin, an
Effusion albumin-like PROTEIN) ensure that the elastic
The passage of fluid through the walls of a tissue is flexible and stretchable. The dermis
blood vessel into a tissue or body cavity. It layer of the skin, arterial walls and the alveolar
commonly occurs as a result of inflammation or walls in the LUNGS all contain elastic tissue.
damage to the blood vessel. A pleural effusion
may occur in heart failure (as a result of Electrical Injuries
increased blood pressure in the veins forcing These are usually caused by the passage through
out fluid) or as a result of inflammation in the the body of an electric current of high voltage
lung tissue (PNEUMONIA). Effusions may also owing to accidental contact with a live wire or
develop in damaged joints. to a discharge of lightning. The general effects
produced are included under the term electric
 226 Electrocardiogram (ECG)

shock, but vary greatly in degree. The local cardiograph. The patient is connected to the
effects include spasmodic contraction of electrocardiograph by leads from either the
muscles, fracture of bones, and in severe cases arms and legs or different points on the chest.
more or less widespread destruction of tissues The normal electrocardiogram of each heart-
which may amount simply to burns of the skin beat shows one wave corresponding to the activ-
or may include necrosis of masses of muscle and ity of the atria and four waves corresponding to
internal organs. Fright due to the unexpected- the phases of each ventricular beat. Various
ness of the shock, and pain due to the sudden readily recognisable changes are seen in cases in
cramp of muscles, are the most common symp- which the heart is acting in an abnormal man-
toms and in most cases pass off within a few ner, or in which one or other side of the heart
E minutes. In more severe cases especially when is enlarged. This record therefore forms a use-
the person has remained in contact with a live ful aid in many cases of heart disease (see
wire for some time, or has been unable to let go HEART, DISEASES OF). The main applications of
of the electrical contact owing to spasmodic the electrocardiogram are in the diagnosis of
contraction of the muscles the effects are myocardial infarction and of cardiac
more pronounced and may include concussion ARRHYTHMIA.
or compression of the brain (see BRAIN, DISEASES
OF). In still more severe cases, death may ensue
either from paralysis of the respiration or stop-
page of the hearts action. If prompt measures
are taken for treatment, the victim can often be
resuscitated.
In Britain there are an average of 110 deaths
a year from electrocution, half of these occur-
ring in the home.

Treatment No electrical apparatus or switch

should be touched by anyone who is in metal-
lic contact with the ground, such as through a
metal pipe, especially, for example, from a
bath. The first action is to break the current.
This can sometimes be done by turning off a
switch. If the victim is grasping or in contact
with a live wire, the contact may be severed
with safety only by someone wearing rubber
gloves or rubber boots; but as these are not
likely to be immediately available, the rescuers
hands may be protected by a thick wrapping
of dry cloth, or the live wire may be hooked or
pushed out of the way with a long wooden
stick such as a broom-handle. If the injured
person is unconscious, and especially if breath-
ing has stopped, artificial respiration should be
applied as described in APPENDIX 1: BASIC
FIRST AID Electrocution. When the patient
begins to breathe again, he or she must be
treated for shock and professional help
obtained urgently.

Electrocardiogram (ECG)
A record of the variations in electric potential
which occur in the HEART as it contracts and
relaxes. Any muscle in use produces an electric
current, but when an individual is at rest, the
main muscular current in the body is that pro-
duced by the heart. This can be recorded by Tracing of normal electrical impulse that initiates
connecting the outside of the body by elec- heartbeat (after The Cardiac Arrhythmias Pocket
trodes with an instrument known as an electro- Book, Boehrringer, Ingelheim).
 Electrolytes 227

Electrocardiography trodes is used. Unilateral ECT has the advan-

A method of recording the electrical activity of tage of being associated with less anterograde
the heart muscles. Electrodes from a recording AMNESIA. When the current passes, the muscles
machine (electrocardiograph) are placed on the will contract for approximately 10 seconds,
skin of the chest wall, arms and legs. The record with further tonic spasms lasting up to a min-
of the electrical changes is called an ECG ute. The patient should then be put in the
(electrocardiogram). The number of elec- COMA or recovery position and observed until
trodes used depends on the complexity of the fully conscious. Up to 12 treatments may be
heart disorder being monitored. The procedure given over a month, improvement usually
can be done in hospital, doctors surgeries and showing after the third session. Widely used at
the patients home, and should not cause any one time, the treatment is now given only E
discomfort. rarely. It can be extremely frightening for
In certain circumstances for example, patients and relatives and is not recommended
where a person has had bouts of chest pain an for children.
exercise ECG may be performed under medical
supervision. The patient walks on a treadmill Electroencephalography (EEG)
while the ECG is recorded continuously. In the BRAIN there is a regular, rhythmical
change of electric potential, due to the rhyth-
Electrocautery mic discharge of energy by nerve cells. These
The use of an electrically heated needle or loop changes can be recorded graphically and the
to destroy diseased or unwanted tissue. Benign brain waves examined a procedure intro-
growths, warts and polyps can be removed with duced to medicine in the 1920s. These records
this technique. electroencephalograms are useful in
DIAGNOSIS: for example, the abnormal electro-
encephalogram occurring in EPILEPSY is charac-
Electrocoagulation teristic of this disease. The normal waves,
A method of sealing blood vessels using heat known as alpha waves, occur with a frequency
generated by high-frequency electric current of 10 per second. Abnormal waves, with a fre-
through fine needles or a surgical knife. The quency of 7 or fewer per second, are known as
procedure is used during surgery to close newly delta waves and occur in the region of cerebral
cut vessels. It can also be used to stop nose- tumours and in the brains of epileptics. An
bleeds and to remove vascular deformities such electroencephalogram can assess whether an
as naevi (see NAEVUS). individual is awake, alert or asleep. It may also
be used during surgery to monitor the depth of
Electrocochleography unconsciousness in anaesthetised patients.
Electrocochleography is a method of recording
the activity of the cochlea, the part of the inner Electrolysis
ear concerned with hearing. (See EAR.) The use of short-wave electric currents to des-
troy the roots of hairs (see SKIN) and so remove
Electroconvulsive Therapy (ECT) unwanted hair from the skin surface. If used by
A controversial but sometimes rapidly effective a trained operator, the procedure is safe, but
treatment for cases of severe DEPRESSION, par- care must be taken in the vicinity of the eyes
ticularly where psychotic features are present and, as electrolysis of hair on the legs is such a
(see PSYCHOSIS), or in high-risk patients such as lengthy process, it is best avoided there.
suicidal or post-partum patients. ECT is only
indicated after antidepressants have been tried Electrolytes
and shown to be ineffective; the full procedure Substances, for example, potassium chloride,
of treatment should be explained to the patient, whose molecules split into their constituent
whose consent must be obtained. electrically charged particles, known as ions,
Before treatment, the patient will have been when dissolved in fluid. In medicine the term is
fasted for at least eight hours. After checking for customarily used to describe the ion itself. The
any potential drug ALLERGY or interactions, description serum electrolyte concentration
the patient is given a general anaesthetic and means the amounts of separate ions for
muscle relaxants. Depending on the side of example, sodium and chloride in the case of
the patients dominance, either unilateral (on salt present in the serum of the circulating
the side of the non-dominant hemisphere of the blood. Various diseases alter the amounts of
BRAIN) or bilateral (if dominance is uncertain, electrolytes in the blood, either because more
e.g. in left-handed people) positioning of elec- than normal are lost through vomiting or diar-
 228 Electromyography (EMG)

rhoea, or because electrolytes may be retained as of proteins in the blood are possible using this
the kidney fails to excrete them properly. Meas- method.
urements of electrolytes are valuable clues to the
type of disease, and provide a means of moni- Electroretinogram
toring a course of treatment. Electrolyte imbal- An electroretinogram is the record of an elec-
ances can be corrected by administering trical response of visual receptors in the retina
appropriate substances orally or intravenously, (see EYE), which can be measured with corneal
or by DIALYSIS. (See APPENDIX 6: MEASURE- electrodes.
MENTS IN MEDICINE.)
Elephantiasis
E Electromyography (EMG) Chronically oedematous (see OEDEMA) and
The recording of electrical activity in a muscle thickened tissue, especially involving the lower
using electrodes placed in the fibres. The pro- extremities and genitalia, which arises from
cedure is used to diagnose muscle and nerve repeated attacks of inflammation of the skin and
disorders and to assess recovery in certain types subcutaneous tissue, with concurrent obstruc-
of paralysis. tion of lymphatic vessels. In a tropical country,
the usual cause is lymphatic FILARIASIS.
Electron
One of the negatively charged subatomic Filarial elephantiasis Wuchereria bancrofti
particles distributed around a positive nucleus and Brugia malayi are conveyed to humans by a
(positron) to form an atom. (See mosquito bite. Resultant lymphatic obstruction
RADIOTHERAPY.) gives rise to enlargement and disfiguration, with
thickening of the skin (resembling that of an
Electronic Monitoring Devices elephant) in one or both lower limbs and
Electronically driven equipment that will con- occasionally genitalia (involving particularly the
stantly monitor the physiological status of SCROTUM). By the time the condition is recog-
patients and the effects of medical intervention nised, lymphatic damage is irreversible. How-
on that status. Such devices should relieve hos- ever, if evidence of continuing activity exists, a
pital staff of time-consuming human monitor- course of diethylcarbamazine should be admin-
ing procedures and in some instances will istered (see FILARIASIS). Relief can be obtained
enable patients to carry monitoring devices dur- by using elastic bandaging, massage, rest, and
ing their daily living activities. An example elevation of the affected limb. Surgery is some-
would be the regular assessment of blood-sugar times indicated. For prevention, destruction of
concentration in subjects with DIABETES MEL- mosquitoes is important.
LITUS or the routine checking on the blood or
tissue concentrations of administered drugs. ELISA
See ENZYME-LINKED IMMUNOSORBENT ASSAY
Electron Microscope (ELISA).
See MICROSCOPE.
Elixir
Electro-Oculography A liquid preparation of a potent or nauseous
A method of recording movements of the eyes, drug made pleasant to the taste by the addition
which is of value in assessing the function of the of aromatic substances and sugar.
retina (see EYE.)
Emaciation
Electrophoresis Pronounced wasting; a common symptom of
The migration of charged particles between many diseases, particularly those which are
electrodes. A simple method of electrophoresis, associated with a prolonged or repeated rise of
known as paper electrophoresis, has been intro- temperature, such as TUBERCULOSIS. It is also
duced to analyse PROTEIN in body fluids. This associated with diseases of the alimentary sys-
method consists in applying the protein- tem in which digestion is inefficient, or in
containing solution as a spot or a streak to a which the food is not fully absorbed: for
strip of filter paper which has been soaked in example, in long-standing diarrhoea, whatever
buffer solution and across the ends of which a its cause. It is also a marked feature of severe
potential difference is then applied for some malnutrition and malignant disease.
hours. Comparison is made between filter strips
of normal fluids and that of the patient under Embalming
investigation. Identification and quantification See DEAD, DISPOSAL OF THE.
 Embryo Transfer 229

Embolectomy Embryo
Surgical removal of a clot or EMBOLUS to clear The FETUS in the womb prior to the end of the
an obstruction in an artery (see ARTERIES, DIS- second month.
EASES OF). The obstruction may be cleared by
inserting a balloon (Fogarty) catheter (see Embryology
CATHETERS) into the blood vessel or by surgical The study of the growth and development of an
incision through the arterial wall. Embolec- EMBRYO and subsequently the FETUS from the
tomy may be a life-saving operation when a fertilisation of the OVUM by the SPERMATO-
patient has a PULMONARY EMBOLISM. ZOON through the gestational period until
birth. Embryology is valuable in the under-
Embolism standing of adult anatomy, how the body
E
The plugging of a small blood vessel by an works and the occurrence of CONGENITAL
EMBOLUS which has been carried through the deformities.
larger vessels by the bloodstream. It is due usu-
ally to fragments of a clot which has formed in Embryo Research
some vessel, or to small portions carried off When a woman is treated for infertility it is
from the edge of a heart-valve when this organ necessary to nurture human embryos for a few
is diseased. However, the plug may also be a days (until the first cell divisions of the fertilised
small mass of bacteria, or a fragment of a egg have occurred) in a specialised laboratory.
tumour, or even a mass of air bubbles sucked More eggs are fertilised than are usually needed
into the veins during operations on the neck. because not all fertilisations are successful. Sur-
The result is usually more or less destruction of plus embryos may be frozen for use in later
the organ or part of an organ supplied by the attempts to implant an embryo in the womb.
obstructed vessel. This is particularly the case in Research has been done on very early embryos
the BRAIN, where softening of the brain, with but the practice is controversial and some coun-
APHASIA or a STROKE, may be the result. If the tries have either forbidden it or imposed tight
plug is a fragment of malignant tumour, a new restrictions. In the UK such research is con-
growth develops at the spot; if it is a mass of trolled by the government Human Fertilisation
bacteria, an ABSCESS forms there. Air-embolism & Embryology Authority (see ASSISTED
occasionally causes sudden death in the case of CONCEPTION).
wounds in the neck, the air bubbles completely
stopping the flow of blood. Fat-embolism is a Embryo Transfer
condition which has been known to cause death Embryo transfer is the process whereby the ini-
masses of fat, in consequence of such an tial stages of procreation are produced outside
injury as a fractured bone, finding their way the human body and completed in the uterus or
into the circulation and stopping the blood in womb. The procedure is also known as embryo
its passage through the lungs. (See also PULMON- transplantation and in vitro fertilisation
ARY EMBOLISM.) (IVF). It consists of extracting an ovum (or egg)
from the prospective mothers body and placing
Embolus this in a dish where it is mixed with the male
Substances for example, air, AMNIOTIC FLUID, partners SEMEN and special nutrient fluids.
blood clot, fat or foreign body that are carried After the ovum is fertilised by the sperm it is
by the blood from a vessel (or vessels) in one transferred to another dish containing a special
part of the body to another part where the mat- nutrient solution. Here it is left for several days
ter lodges in a blood vessel causing a blockage while the normal early stages of development
(see EMBOLISM). (see FETUS) take place. The early EMBRYO, as it
has then become, is then implanted in the
Embrocations mothers uterus, where it takes root and
Embrocations are mixtures, usually of an oily develops as a normal fetus.
nature, intended for external application in The first test-tube baby to use the popu-
cases of rheumatism, sprains, and other pain- lar, and widely used, term for such a child was
ful conditions. Their action is due mainly to born by CAESAREAN SECTION in England on 25
the massage employed in rubbing in the July 1978. Many other children conceived in
embrocations, in part to the counter-irritant this manner have since been born, and, though
action of the drugs which they contain. (See only 10 per cent of women conceive at the first
LINIMENTS.) attempt, the overall success rate is improving.
Embryo transplantation and research are con-
troversial procedures and in many countries,
 230 Emergency

including the UK, are controlled by legislation. lance, and be ready to give the name of the
Embryo transfer and research using embryos person involved, a brief description of the
are regulated by the Human Fertilisation emergency and the place where it has
& Embryology Authority (see ASSISTED occurred.
CONCEPTION; APPENDIX 7: STATUTORY
ORGANISATIONS). Emesis
Emesis means VOMITING.
Emergency
A condition that needs urgent medical care. Emetics
Examples include life-threatening injuries An emetic is a substance which induces VOMIT-
E involving blood loss or damage to major organs, ING (emesis). Emetics were previously used for
cardiac arrest or sudden loss of consciousness gut decontamination in the treatment of
from, say, a blow or an epileptic fit. Emergency poisoning but are now considered obsolete.
is a term also applied to any resuscitative pro- This is because the efficacy of emesis as a means
cedure that must be undertaken immediately of gut decontamination is unproved; there is a
for instance, cardiopulmonary resuscitation (see delay between administration and actual
APPENDIX 1: BASIC FIRST AID Cardiac/respira- emesis, during which time continued absorp-
tory arrest) or TRACHEOSTOMY. Patients with tion of the poison may occur; and some emetics
an emergency condition may initially be treated have effects other than vomiting which may
on the spot by suitably qualified paramedical mask the clinical features of the ingested poi-
staff before being transported by road or air son. The most commonly used emetic was
ambulance to a hospital Accident and Emer- syrup of ipecacuanha (ipecac). Salt (sodium
gency department, also known as an A&E or chloride) water emetics were also used but there
Casualty department. These departments are are many cases of fatal HYPERNATRAEMIA result-
staffed by doctors and nurses experienced in ing from such use and salt water emetics should
dealing with emergencies; their first job when never be given. The most common method of
an emergency arrives is to conduct a TRIAGE gut decontamination currently used is the
assessment to decide the seriousness of the administration of activated CHARCOAL.
emergency and what priority the patient should
be given in the context of other patients need- Emetine
ing emergency care. The active principles of IPECACUANHA.
As their title shows, A&E departments (and
the 999 and 112 telephone lines) are for EMG
patients who are genuine emergencies: namely, See ELECTROMYOGRAPHY (EMG).
critical or life-threatening circumstances such as:
unconsciousness. Emission
serious loss of blood. A discharge. The term is commonly used to
suspected broken bones. describe the orgasmic flow of SEMEN from the
deep wound(s) such as a knife wound. erect PENIS that occurs during sleep. Described
suspected heart attack. as a nocturnal emission or, colloquially, as a
difficulty in breathing. wet dream, it is a common event in late
suspected injury to brain, chest or abdominal
organs.
PUBERTY.

fits.
To help people decide which medical service
EMLA
This is a proprietary brand of topical cream (the
is most appropriate for them (or someone they abbreviation stands for Eutectic Mixture of
are caring for or helping), the following ques- Local Anaesthetics). EMLA has revolutionised
tions should be answered: the care of children in hospital in the last dec-
Could the symptoms be treated with an over- ade by allowing blood-taking, lumbar puncture
the-counter (OTC) medicine? If so, visit a and other invasive procedures to be conducted
pharmacist. relatively painlessly. It is applied to the skin and
Does the situation seem urgent? If so, call covered. After one hour the skin is
NHS Direct or the GP for telephone advice, anaesthetised.
and a surgery appointment may be the best
action. Emmetropia
Is the injured or ill person an obvious emer- The normal condition of the EYE as regards
refraction of light rays. When the muscles in
gency (see above)? If so, go to the local
A&E department or call 999 for an ambu- the eyeball are completely relaxed, the focusing
 Empyema 231

power is accurately adjusted for parallel rays, so tissue an unmistakable crackling feel when
that vision is perfect for distant objects. touched. X-rays of an affected area will usually
show the presence of air. Such air is generally
Emollients absorbed by the body when the leak has been
Emollients are substances which have a soften- sealed.
ing and soothing effect upon the skin. They The second type of emphysema affects the
include dusting powders such as French chalk, lung tissue and is called pulmonary emphy-
oils such as olive oil and almond oil, and fats sema. It is now grouped with other lung dis-
such as the various pharmacopoeial prepar- orders such as chronic BRONCHITIS and some
ations of paraffin, suet, and lard. Glycerin is types of ASTHMA under the umbrella heading
also an excellent emollient. CHRONIC OBSTRUCTIVE PULMONARY DISEASE
E
(COPD). See under this entry for further
Uses They are used in various inflammatory information.
conditions such as eczema (see DERMATITIS),
when the skin becomes hard, cracked, and pain- Empirical
ful. They may be used in the form of a dusting Method of treatment founded simply on
powder, an oil or an ointment. experience rather than on scientific evidence
from, for example, clinical trials. Because a
Emotion given remedy has been successful in the treat-
Mental arousal that the individual may find ment of a certain group of symptoms, it is
enjoyable or unpleasant. The three components assumed, by those who uphold this principle,
are subjective, physiological and behavioural. that it will be successful in the treatment of
The instinctive fear and flee response in animals other cases presenting similar groups of symp-
comprises physiological reaction raised heart toms, without any inquiry as to the cause of the
rate, pallor and sweating to an unpleasant symptoms or reason underlying the action of
event or stimulus. The loving relationship the remedy. It is the contrary of rational or
between mother and child is another well- scientific treatment. Sometimes empirical
recognised emotional event. If this emotional treatment is a reasonable course of action where
bond is absent or inadequate, the child may there is no known proven effective treatment
suffer emotional deprivation, which can be the for a condition.
trigger for behavioural problems ranging from
attention-craving to aggression. Emotional Empyema
problems are common in human society, cover- An accumulation of PUS within a cavity, the
ing a wide spectrum of psychological disturb- term being generally reserved for collections of
ances. Upbringing, relationships or psychiatric pus within one of the pleural cavities (see
illnesses such as anxiety and DEPRESSION may LUNGS). Since the advent of antibiotics, the
all contribute to the development of emotional condition is relatively uncommon in
problems (see MENTAL ILLNESS). developed countries. The condition is virtually
an ABSCESS, and therefore gives rise to the
Empathy general symptoms accompanying that condi-
The facility to understand and be sympathetic tion. However, on account of the thick,
to the feelings and thoughts of another indi- unyielding wall of the chest, it is unlikely to
vidual. Empathy in the therapist is an essential burst through the surface, and therefore it is
component of successful psychotherapy and is a of particular importance that the condition
valuable characteristic in anyone who is a should be recognised early and treated
member of a caring profession. adequately.
The condition most commonly follows an
Emphysema attack of PNEUMONIA; it may also occur in the
The presence of air in the bodys tissues. Div- advanced stage of pulmonary TUBERCULOSIS.
ided into two types, surgical and pulmonary Empyema also occurs at times through infec-
emphysema, the former occurs when air escapes tion from some serious disease in neighbour-
from leaks in the LUNGS and OESOPHAGUS ing organs, such as cancer of the GULLET, or
perhaps as the result of injury or infection and follows upon wounds penetrating the chest
collects in the tissues of the chest and neck. Air wall.
occasionally escapes into other tissues as a result Treatment may be by surgery or by drainage
of surgery or injury, and bacterial infection can through a tube inserted into the pleural cavity,
also produce gas in soft tissues (see gas gangrene combined with instillation of agents which
under GANGRENE). Air or gas gives the affected break down the secretions.
 232 Emulsions

Emulsions disturbance, and epileptic fits. Rabies is always

Emulsions are oil-in-water or water-in-oil dis- fatal and the changes found in patients with
persions. Therapeutic emulsions (creams) AIDS are almost always progressive. Except in
require an added stabilising substance. very specific circumstances, it is not possible to
be immunised against encephalitis.
Enamel Encephalitis lethargica is one, now rare, var-
See TEETH. iety that reached epidemic levels after World
War I. It was characterised by drowsiness and
Encephalin headache leading on to COMA. The disease
A naturally occurring brain PEPTIDE, the effects occasionally occurs as a complication after
E of which resemble those of MORPHINE or other mumps and sometimes affected individuals
opiates (see ENDORPHINS; ENKEPHALINS). subsequently develop postencephalitic
PARKINSONISM.
Encephalitis
Encephalitis means inflammation or infection Encephaloid
of the brain, usually caused by a virus; it may A form of cancer which, to the naked eye,
also be the result of bacterial infection. It occurs resembles the tissue of the brain.
throughout the world and affects all racial
groups and ages. Rarely it occurs as a complica- Encephalomyelitis
tion of common viral disease such as measles, Inflammation of the substance of both brain
mumps, glandular fever, or chickenpox. It may and spinal cord.
occur with no evidence of infection elsewhere,
such as in HERPES SIMPLEX encephalitis, the Encephalopathy
most common form seen in Europe and Amer- The term covering certain conditions in which
ica. RABIES is another form of viral encephalitis, there are signs of cerebral irritation without
and the HIV virus which causes AIDS invades any localised lesion to account for them.
the brain to cause another form of encephalitis Examples are HYPERTENSIVE ENCEPHAL-
(see AIDS/HIV). In some countries North and OPATHY, SPONGIFORM ENCEPHALOPATHY,
South America, Japan and east Asia and Russia WERNICKES ENCEPHALOPATHY and lead
there may be epidemics spread by the bite of encephalopathy. In the first, which occurs in
mosquitoes or ticks. the later stages of chronic glomerulonephritis
The clinical features begin with influenza- (see KIDNEYS, DISEASES OF), or URAEMIA, the
like symptoms aches, temperature and headache, convulsions and delirium which con-
wretchedness; then the patient develops a head- stitute the main symptoms are supposed to be
ache with drowsiness, confusion and neck stiff- due to a deficient blood supply to the brain.
ness. Severely ill patients develop changes in
behaviour, abnormalities of speech, and Enchondroma
deterioration, sometimes with epileptic seiz- A TUMOUR formed of cartilage.
ures. Some develop paralysis and memory loss.
CT (see COMPUTED TOMOGRAPHY) and MRI Encysted
brain scans show brain swelling, and damage to Enclosed within a bladder-like wall. The term is
the temporal lobes if the herpes virus is applied to parasites, collections of pus, etc.,
involved. ELECTROENCEPHALOGRAPHY (EEG), which are shut off from surrounding tissues by
which records the brainwaves, is abnormal. a membrane or by adhesions.
Diagnosis is possible by an examination of the
blood or other body fluids for antibody reaction Endarterectomy
to the virus, and modern laboratory techniques Surgical reopening of an artery obstructed by
are very specific. ATHEROMA. If a blood clot is present, the re-
In general, drugs are not effective against vir- boring process is called thromboendarterec-
uses antibiotics are of no use. Herpes encepha- tomy. Restored patency allows arterial blood
litis does respond to treatment with the anti- supply to restart. The carotid arteries and
viral agent, aciclovir. Treatment is supportive: arteries to the legs are those most commonly
patients should be given painkillers, and fluid operated on.
replacement drugs to reduce brain swelling and
counter epilepsy if it occurs. Fortunately, most Endarteritis
sufferers from encephalitis make a complete Inflammation of the inner coat of an artery. (See
recovery, but some are left severely disabled ARTERIES, DISEASES OF.)
with physical defects, personality and memory
 Endocrine Glands 233

Endemic muscles and the coronary arteries are dilated;

A term applied to diseases which exist in par- systolic blood pressure rises; blood sugar
ticular localities or among certain races. Some increases; the metabolic rate rises; muscle
diseases, which are at times EPIDEMIC over wide fatigue is diminished. The superficial or cortical
districts, have a restricted area where they are part of the glands produces steroid-based sub-
always endemic, and from which they spread. stances such as aldosterone, cortisone, hydro-
For example, both CHOLERA and PLAGUE are cortisone, and deoxycortone acetate, for the
endemic in certain parts of Asia. maintenance of life. It is the absence of these
substances, due to atrophy or destruction of the
Endo- suprarenal cortex, that is responsible for the
E
Prefix meaning situated inside. condition known as ADDISONS DISEASE. (See
CORTICOSTEROIDS.)
Endocarditis
Inflammation of the lining, valves and muscle Ovaries and testicles The ovary (see
of the HEART. The main causes are bacterial and OVARIES) secretes at least two hormones
virus infections and rheumatic fever, and the known, respectively, as oestradiol (follicular
condition occurs most often in patients whose hormone) and progesterone (corpus luteum
ENDOCARDIUM is already damaged by con- hormone). Oestradiol develops (under the
genital deformities or whose immune system stimulus of the anterior pituitary lobe see
has been suppressed by drugs. Infection may be PITUITARY GLAND below, and under separate entry)
introduced into the bloodstream during dental each time an ovum in the ovary becomes
treatment or surgical procedures, especially on mature, and causes extensive proliferation of
the heart or on the gastrointestinal system. The the ENDOMETRIUM lining the UTERUS, a stage
condition is potentially very serious and treat- ending with shedding of the ovum about 14
ment is with large doses of antibiotic drugs. (See days before the onset of MENSTRUATION. The
HEART, DISEASES OF.) corpus luteum, which then forms, secretes both
progesterone and oestradiol. Progesterone
Endocardium brings about great activity of the glands in the
A thin membrane consisting of flat endothelial endometrium. The uterus is now ready to
cells; it lines the four chambers of the HEART receive the ovum if it is fertilised. If fertilisation
and is continuous with the lining of arteries and does not occur, the corpus luteum degenerates,
veins. The endocardium has a smooth surface the hormones cease acting, and menstruation
which helps the blood to flow easily. The valves takes place.
at the openings of the hearts chambers are The hormone secreted by the testicles (see
made from folded-up membranes. Inflamma- TESTICLE) is known as TESTOSTERONE. It is
tion of the endocardium is called responsible for the growth of the male second-
ENDOCARDITIS. ary sex characteristics.

Endocrine Glands Pancreas This gland is situated in the upper

Organs whose function it is to secrete into the part of the abdomen and, in addition to the
blood or lymph, substances known as HOR- digestive enzymes, it produces INSULIN within
MONES. These play an important part in gen- specialised cells (islets of Langerhans). This
eral changes to or the activities of other organs controls carbohydrate metabolism; faulty or
at a distance. Various diseases arise as the result absent insulin production causes DIABETES
of defects or excess in the internal secretions of MELLITUS.
the different glands. The chief endocrine glands
are: Parathyroid glands These are four minute
glands lying at the side of, or behind, the thy-
Adrenal glands These two glands, also roid (see below). They have a certain effect in
known as suprarenal glands, lie immediately controlling the absorption of calcium salts by
above the kidneys. The central or medullary the bones and other tissues. When their secre-
portion of the glands forms the secretions tion is defective, TETANY occurs.
known as ADRENALINE (or epinephrine) and
NORADRENALINE. Adrenaline acts upon struc- Pituitary gland This gland is attached to
tures innervated by sympathetic nerves. Briefly, the base of the brain and rests in a hollow on
the blood vessels of the skin and of the abdom- the base of the skull. It is the most important of
inal viscera (except the intestines) are con- all endocrine glands and consists of two
stricted, and at the same time the arteries of the embryologically and functionally distinct lobes.
 234 Endocrine Glands

The function of the anterior lobe depends on COSTEROIDS). The pharmacologically active
the secretion by the HYPOTHALAMUS of certain polypeptide of ACTH has been synthesised and
neuro-hormones which control the secretion is called tetracosactrin. Thyrotrophic hormone
of the pituitary trophic hormones. The hypo- is also available but it has no therapeutic
thalamic centres involved in the control of application.
specific pituitary hormones appear to be ana-
tomically separate. Through the pituitary HYPOTHALAMIC RELEASING HORMONES which
trophic hormones the activity of the thyroid, affect the release of each of the six anterior pitu-
adrenal cortex and the sex glands is controlled. itary hormones have been identified. Their
The anterior pituitary and the target glands are blood levels are only one-thousandth of those of
E linked through a feedback control cycle. The the pituitary trophic hormones. The release of
liberation of trophic hormones is inhibited by a thyrotrophin, adrenocorticotrophin, growth
rising concentration of the circulating hormone hormone, follicle-stimulating hormone and
of the target gland, and stimulated by a fall in luteinising hormone is stimulated, while release
its concentration. Six trophic (polypeptide) of prolactin is inhibited. The structure of the
hormones are formed by the anterior pituitary. releasing hormones for TSH, FSH-LH, GH
Growth hormone (GH) and prolactin are sim- and, most recently, ACTH is known and they
ple proteins formed in the acidophil cells. have all been synthesised. Thyrotrophin-
Follicle-stimulating hormone (FSH), luteinis- releasing hormone (TRH) is used as a diag-
ing hormone (LH) and thyroid-stimulating nostic test of thyroid function but it has no
hormone (TSH) are glycoproteins formed in therapeutic application. FSH-LH-releasing
the basophil cells. Adrenocorticotrophic hor- hormone provides a useful diagnostic test of
mone (ACTH), although a polypeptide, is gonadotrophin reserve in patients with pituit-
derived from basophil cells. ary disease, and is now used in the treatment
The posterior pituitary lobe, or neuro- of infertility and AMENORRHOEA in patients
hypophysis, is closely connected with the hypo- with functional hypothalamic disturbance. As
thalamus by the hypothalamic-hypophyseal this is the most common variety of secondary
tracts. It is concerned with the production amenorrhoea, the potential use is great. Most
or storage of OXYTOCIN and vasopressin (the cases of congenital deficiency of GH, FSH,
antidiuretic hormone). LH and ACTH are due to defects in the
hypothalamic production of releasing hor-
PITUITARY HORMONES Growth hormone, mone and are not a primary pituitary defect,
gonadotrophic hormone, adrenocorticotrophic so that the therapeutic implication of this syn-
hormone and thyrotrophic hormones can be thesised group of releasing hormones is
assayed in blood or urine by radio-immuno- considerable.
assay techniques. Growth hormone extracted GALACTORRHOEA is frequently due to a
from human pituitary glands obtained at aut- microadenoma (see ADENOMA) of the pituitary.
opsy was available for clinical use until 1985, DOPAMINE is the prolactin-release inhibiting
when it was withdrawn as it is believed to carry hormone. Its duration of action is short so its
the virus responsible for CREUTZFELDT-JAKOB therapeutic value is limited. However, BRO-
DISEASE (COD). However, growth hormone MOCRIPTINE is a dopamine agonist with a more
produced by DNA recombinant techniques is prolonged action and is effective treatment for
now available as somatropin. Synthetic growth galactorrhoea.
hormone is used to treat deficiency of the nat-
ural hormone in children and adults, TURNERS Thyroid gland The functions of the thyroid
SYNDROME and chronic renal insufficiency in gland are controlled by the pituitary gland (see
children. above)and the hypothalamus, situated in the
Human pituitary gonadotrophins are readily brain. The thyroid, situated in the front of
obtained from post-menopausal urine. Com- the neck below the LARYNX, helps to regulate
mercial extracts from this source are available the bodys METABOLISM. It comprises two
and are effective for treatment of infertility due lobes each side of the TRACHEA joined by an
to gonadotrophin insufficiency. isthmus. Two types of secretory cells in the
The adrenocorticotrophic hormone is gland follicular cells (the majority) and
extracted from animal pituitary glands and has parafollicular cells secrete, respectively, the
been available therapeutically for many years. It iodine-containing hormones THYROXINE (T4)
is used as a test of adrenal function, and, under and TRI-IODOTHYRONINE (T3), and the hor-
certain circumstances, in conditions for which mone CALCITONIN. T3 and T4 help control
corticosteroid therapy is indicated (see CORTI- metabolism and calcitonin, in conjunction with
 Endoscopy 235

parathyroid hormone (see above), regulates the End Organ

bodys calcium balance. Deficiencies in thyroid A structure at the end of a peripheral nerve that
function produce HYPOTHYROIDISM and, in acts as receptor for a sensation. For example, the
children, retarded development. Excess thyroid olfactory nerves have end organs that identify
activity causes thyrotoxicosis. (See THYROID smells.
GLAND, DISEASES OF.)
Endorphins
Endocrinology Peptides (see PEPTIDE) produced in the brain
The study of the endocrine system, the sub- which have a pain-relieving action; hence their
stances (hormones) it secretes and its disorders alternative name of opiate peptides. Their name
(see ENDOCRINE GLANDS.) is derived from endogenous MORPHINE. They E
have been defined as endogenous opiates or any
Endoderm naturally occurring substances in the brain with
The inner layer of the three germ layers of the pharmacological actions resembling opiate
EMBRYO during its early development. The alkaloids such as morphine. There is some evi-
endoderm develops into the lining of the gas- dence that the pain-relieving action of ACU-
trointestinal tract and associated glands (LIVER; PUNCTURE may be due to the release of these
gall-bladder see LIVER; PANCREAS), the lining opiate peptides. It has also been suggested that
of the bronchi and alveoli of the LUNGS and they may have an antipsychotic action and there-
much of the URINARY TRACT. fore be of value in the treatment of major psych-
otic illnesses such as SCHIZOPHRENIA.
Endogenous
Coming from within the body. Endogenous Endoscope
depression, for instance, occurs as a result of A tube-shaped instrument inserted into a cavity
causes inside a person. in the body to investigate and treat disorders. It
is flexible and equipped with lenses and a light
Endolymph source. Examples of endoscopes are the CYSTO-
The fluid that fills the membranous labyrinth of SCOPE for use in the bladder, the GASTROSCOPE
the inner ear (see EAR). for examining the stomach and the ARTHRO-
SCOPE for looking into joints (see also FIBREOP-
Endometriosis TIC ENDOSCOPY).
The condition in which the endometrium (the
cells lining the interior of the UTERUS) is found Endoscopic Retrograde
in other parts of the body. The most common Cholangiopancreatography
site of such misplaced endometrium is the (ERCP)
muscle of the uterus. The next most common This is a procedure in which a catheter (see
site is the ovary (see OVARIES), followed by the CATHETERS) is passed via an ENDOSCOPE into
PERITONEUM lining the PELVIS, but it also the AMPULLA OF VATER of the common BILE
occurs anywhere in the bowel. The cause is not DUCT. The duct is then injected with a radio-
known. Endometriosis never occurs before opaque material to show up the ducts radio-
puberty and seldom after the menopause. The logically. The technique is used to diagnose
main symptoms it produces are MENOR- pancreatic disease as well as obstructive
RHAGIA, DYSPAREUNIA, painful MENSTRUATION jaundice.
and pelvic pain. Treatment is usually by
removal of the affected area, but in some cases Endoscopy
satisfactory results are obtained from the Examination of a body cavity for example,
administration of a PROGESTOGEN such as PLEURAL CAVITY, GASTROINTESTINAL TRACT,
NORETHISTERONE, norethynodrel and BILE DUCT and URINARY BLADDER using an
DANAZOL. ENDOSCOPE in order to diagnose or treat a dis-
order in the cavity. The development of
Endometritis endoscopy has reduced the need for major sur-
Inflammation of the mucous membrane lining gery, as many diagnostic procedures can be per-
the womb. (See UTERUS, DISEASES OF.) formed with an endoscope (as can MINIMALLY
INVASIVE SURGERY (MIS)). The development of
Endometrium fibre optics (the transmission of light along
The mucous membrane which lines the interior bundles of glass or plastic fibres) has greatly
of the UTERUS. advanced the practice of endoscopy and hos-
pitals now routinely run endoscopy clinics on
 236 Endothelium

an out-patient basis, often without the necessity

for a general anaesthetic.

Endothelium
The membrane lining various vessels and cav-
ities of the body, such as the pleura (lining the
lung), the pericardium (lining the heart), the
peritoneum (lining the abdomen and abdom-
inal organs), the lymphatic vessels, blood ves-
sels, and joints. It consists of a fibrous layer
E covered with thin flat cells, which render the
surface perfectly smooth and secrete the fluid
for its lubrication.

Endotoxin
A poison produced by certain gram-negative
bacteria that is released after the micro-
organisms die. Endotoxins can cause fever and
shock, the latter by rendering the walls of blood
vessels permeable so that fluid leaks into the
tissues, with a consequent sharp fall in blood
pressure. (See EXOTOXIN.)

Endotracheal Intubation
Insertion of a rubber or plastic tube through the
nose or mouth into the TRACHEA. The tube
often has a cuff at its lower end which, when
inflated, provides an airtight seal. This allows an
anaesthetist to supply oxygen or anaesthetic
gases to the lungs with the knowledge of exactly
how much the patient is receiving. Endotra-
cheal intubation is necessary to undertake arti-
ficial ventilation of a patient (see ANAESTHESIA).

Enema
Introduction of fluid into the RECTUM via the

A fibreoptic bronchoscope used to examine the larger bronchial tubes of the lungs to determine, for
example, whether a tumour is present.
 ENT Disorders 237

Percutaneous nephroscope used for examining the interior of the kidney. It is passed into the pelvis of the
kidney through a track from the surface of the skin. (The track is made with a needle and guide wire.)
Instruments can be passed through the nephroscope under direct vision to remove calculi.

ANUS. Enemas may be given to clear the intes- ing part of the baby, usually the head, moves
tine of faeces prior to intestinal surgery or to down into the mothers pelvis. (See PREGNANCY
relieve severe constipation. They may also be AND LABOUR.)
used to give barium for diagnostic X-rays as well
as drugs such as CORTICOSTEROIDS, used to Enkephalins
treat ULCERATIVE COLITIS. The patient is Peptides (see PEPTIDE) that have a pain-killing
placed on his or her side with a support under effect similar to that of ENDORPHINS. Produced
the hips. A catheter (see CATHETERS) with a by certain nerve endings and in the brain,
lubricated end is inserted into the rectum and enkephalins (also spelt encephalins) are also
warmed enema fluid gently injected. Dispos- believed to act as a sedative and mood-changer.
able enemas and miniature enemas, which can
be self-administered, are widely used; they con- Enophthalmos
tain preprepared solution. Abnormal retraction of the eye into its socket:
for example, when the sympathetic nerve in the
Enflurane neck is paralysed.
A volatile inhalational anaesthetic similar to
HALOTHANE but less potent and less likely to Entamoeba
have toxic effects on the LIVER. See AMOEBA.

Engagement ENT Disorders

The event during pregnancy when the present- See OTORHINOLARYNGOLOGY.
 238 Enteral Feeding

Enteral Feeding and south-east Asia. Infection occasionally

In severely ill patients, the metabolic responses occurs in southern and eastern Europe, particu-
to tissue damage may be sufficient to cause a larly with S. paratyphi B. However, in northern
reduction of muscle mass and of plasma pro- and western Europe and North America, most
teins. This state of CATABOLISM may also impair cases are imported.
the immune response to infection and delay the
healing of wounds. It is probable that as many Clinical course The incubation period of
as one-half of patients who have had a major enteric fever is 721 days. Early symptoms
operation a week previously show evidence of include headache, malaise, dry cough, constipa-
protein malnutrition. This can be detected clin- tion and a slowly rising fever. Despite the fever,
E ically by a loss of weight and a reduction in the the patients pulse rate is often slow and he or
skinfold thickness and arm circumference. Bio- she may have an enlarged SPLEEN. In the second
chemically the serum-albumin (see ALBUMINS) week of illness, organisms invade the blood-
concentration falls, as does the LYMPHOCYTE stream again and symptoms progress. In gen-
count. The protein reserves of the body fall eral, symptoms of typhoid fever are more severe
even more dramatically when there are SEPSIS, than those of paratyphoid fever: increasing
burns, acute pancreatitis or renal failure. mental slowness and confusion are common,
The purpose of enteral feeding is to give a and a more sustained high fever is present. In
liquid, low-residue food through a naso-gastric some individuals, discrete red spots appear on
feeding tube. It has the advantage over par- the upper trunk (rose spots). By the third week
enteral nutrition that the septic complications of illness the patient may become severely toxic,
of insertion of CATHETERS into veins are with marked confusion and delirium, abdom-
avoided. Enteral feeding may either take the inal distension, MYOCARDITIS, and occasionally
form of intermittent feeding through a large- intestinal haemorrage and/or perforation. Such
bore naso-gastric tube, or of continuous complications may be fatal, although they are
gravity-feeding through a fine-bore tube. unusual if prompt treatment is given. Symp-
A number of proprietary enteral foods are toms improve slowly into the fourth and fifth
available. Some contain whole protein as the weeks, although relapse may occur.
nitrogen source; others and these are called
elemental diets contain free amino acids. Diagnosis Enteric fever should be considered
DIARRHOEA is the most common problem with in any traveller or resident in an ENDEMIC area
enteral feeding and it tends to occur when presenting with a febrile illness. The most
enteral feeding is introduced too rapidly or with common differential diagnosis is MALARIA.
too strong a preparation. Diagnosis is usually made by isolation of the
organism from cultures of blood in the first two
Enteralgia weeks of illness. Later the organisms are found
Another name for COLIC. in the stools and urine. Serological tests for
ANTIBODIES against Salmonella typhi antigens
Enteric-Coated (see ANTIGEN) (the Widal test) are less useful
A description of tablets covered in material that due to cross-reactions with antigens on other
allows them to pass through the stomach and bacteria, and difficulties with interpretation in
enter the intestine unaltered. Drugs coated in individuals immunised with typhoid vaccines.
this way are those whose action is reduced or
stopped by acid in the stomach. Treatment Where facilities are available,
hospital admission is required. Antibiotic ther-
Enteric Fever apy with chloramphenicol or amoxyacillin is
Enteric fever is caused by bacterial infection effective. However, the potential toxicity of the
with either Salmonella typhi or Salmonella para- former and the widespread resistance that has
typhi A, B or C. These infections are called developed to both these antibiotics has led to
typhoid fever, or paratyphoid fever respectively. the use of QUINOLONES such as CIPROFLOXACIN
Transmission usually occurs by ingestion of as the initial therapy for enteric fever in the UK
water or food that has been contaminated with and in areas where resistant organisms are
human faeces for example, by drinking water common. A few individuals become chronic
contaminated with sewage, or eating foods pre- carriers of the organisms after they have
pared by a cook infected with or carrying the recovered from the symptoms. These people are
organisms. Enteric fever is ENDEMIC in many a potential source of spread to others and
areas of the world, including Africa, Central should be excluded from occupations that
and South America, the Indian subcontinent involve handling food or drinking-water.
 Enuresis 239

Prolonged courses of antibiotic therapy may be part of the intestine or brought to the exterior
required to eradicate carriage. via the abdominal wall.

Prevention Worldwide, the most important Enterotoxin

preventive measure is improvement of sanita- A type of toxin (see TOXINS) that causes inflam-
tion and maintenance of clean water supplies. mation of the intestinal lining and results in
Vaccination is available for travellers to endemic vomiting and diarrhoea (see FOOD POISONING).
areas.
Enteroviruses
Enteritis A family of VIRUSES which include the POLIO-
MYELITIS, COXSACKIE and ECHO (see ECHOVI-
E
Enteritis means inflammation of the intestines.
(See DIARRHOEA; INTESTINE, DISEASES OF.) RUSES) groups of viruses. Their importance lies
in their tendency to invade the central nervous
Enterobiasis system. They receive their name from the fact
Infection with Enterobius vermicularis, the that their mode of entry into the body is
threadworm (or pinworm as it is known in the through the gut.
USA). It is the most common of all the intes-
tinal parasites in Britain, and the least harmful. Entonox
The male is about 6 mm ( inch) in length and A proprietary analgesic drug taken by inhal-
the female about 12 mm ( inch) in length. ation and comprising half nitrous oxide and
Each resembles a little piece of thread. These half oxygen. It is valuable in providing relief to
worms live in considerable numbers in the casualties who are in pain, as it provides
lower bowel, affecting children particularly. analgesia without making them unconscious.
They usually cause no symptoms but can result Entonox is also used in obstetric practice to ease
in great irritation round the anus or within the the pains of childbirth.
female genitalia, especially at night when the
female worm emerges from the anus to lay its Entropion
See EYE, DISORDERS OF.
eggs and then die. The most effective form of
treatment is either viprynium embonate or
piperazine citrate, which needs to be taken by Enuresis
the whole family. Bedclothes must then be Bed-wetting, or the involuntary passage of
laundered. urine at night. It can occur at all ages but is a
particular problem with children and the eld-
erly. In general, paediatricians prefer not to
Enterocele treat enuresis much before the age of six, as it
A HERNIA of the bowel.
may be a normal phenomenon and usually
stops as the child grows older. However, when
Enterogastrone the condition persists, the child (and parents)
A hormone derived from the mucosal lining of need advice. Treatment is by positive
the small intestine which inhibits the move- reinforcement of bladder control, alarm sys-
ments and secretion of the stomach. tems such as the pad and bell, or ocasionally
by drugs such as Desmopressin, which reduces
Enterokinase night-time urinary output. Some children have
The ENZYME secreted in the DUODENUM and an irritable bladder and can be helped by
jejunum (see INTESTINE) which converts the drugs which relieve this. Enuresis is often a
enzyme, trypsinogen, secreted by the PAN- result of psychological disturbance, particularly
CREAS, into TRYPSIN. (See also DIGESTION.) where family relationships are disrupted. In this
circumstance medication is unlikely to be
Enteroptosis effective.
A condition in which, owing to a lax condition Constipation is a common cause of urinary
of the mesenteries (see MESENTERY) and liga- incontinence and hence bed-wetting in the
ments which support the intestines, the latter elderly and should be treated. Enuresis in the
descend into the lower part of the abdominal elderly may also be due to organic disease or to
cavity. mental deterioration and confusion. Appropri-
ate investigation, treatment and nursing should
Enterostomy be arranged. (See NOCTURNAL ENURESIS.)
An operation by which an artificial opening is Advice is available from the Enuresis
formed into the intestine and joined to another Resource and Information Centre (ERIC)
 240 Environmental Health Officer

whose weekday helpline is 0117 960 3060. Also ities. They may be directly harmful, as in the
www.eric.org.uk examples of exposure to toxic chemicals at
work, pesticides, or air pollution from road
Environmental Health Officer transport, or to radon gas penetrating domestic
A local-authority health official specially quali- properties. Environmental factors may also alter
fied in aspects of environmental health such as peoples susceptibility to disease: for example,
clean air, food hygiene, housing, pollution, the availability of sufficient food. In addition,
sanitation and water supplies. He or she is they may operate by making unhealthy choices
responsible for running the authoritys more likely, such as the availability and afford-
environmental health department and, when ability of junk foods, alcohol, illegal drugs or
E epidemiological advice is needed, the relevant tobacco.
public-health physician acts in a consultative
capacity (see EPIDEMIOLOGY; PUBLIC HEALTH). Populations at risk Children are among
the populations most sensitive to environ-
Environmental Medicine mental health hazards. Their routine exposure
The study of the consequences for peoples to toxic chemicals in homes and communities
health of the natural environment. This can put their health at risk. Central to the abil-
includes the effects of climate, geography, sun- ity to protect communities and families is the
light and natural vegetation. right of people to know about toxic substances.
For many, the only source of environmental
Environment and Health information is media reporting, which often
Environment and Health concerns those leaves the public confused and frustrated. To
aspects of human health, including quality of benefit from public access to information,
life, that are determined by physical, biological, increasingly via the Internet, people need basic
social and psychosocial factors in the environ- environmental and health information,
ment. The promotion of good health requires resources for interpreting, understanding and
not only public policies which support health, evaluating health risks, and familiarity with
but also the creation of supportive environ- strategies for prevention or reduction of risk.
ments in which living and working conditions
are safe, stimulating and enjoyable. Risk assessment Environmental health
Health has driven much of environmental experts rely on the principles of environmental
policy since the work of Edwin Chadwick in toxicology and risk assessment to evaluate the
the early 1840s. The first British public-health environment and the potential effects on indi-
act was introduced in 1848 to improve housing vidual and community health. Key actions
and sanitation with subsequent provision of include:
purified water, clean milk, food hygiene regula-
tions, vaccinations and antibiotics. In the 21st
identifying sources and routes of environ-
mental exposure and recommending
century there are now many additional methods of reducing environmental health
environmental factors that must be monitored, risks, such as exposure to heavy metals, solv-
researched and controlled if risks to human ents, pesticides, dioxins, etc.
health are to be well managed and the impact
on human morbidity and mortality reduced.
assessing the risks of exposure-related health
hazards.
Environmental impacts on health include: alerting health professionals, the public, and
noise the media to the levels of risk for particular
air pollution potential hazards and the reasons for
water pollution interventions.
dust ensuring that doctors and scientists explain
odours the results of environmental monitoring
contaminated ground studies for example, the results of water
loss of amenities fluoridation in the UK to improve dental
vermin health.
vibration
animal diseases National policies In the United Kingdom
in 1996, an important step in linking environ-
Environmental risk factors Many of the ment and health was taken by a government-
major determinants of health, disease and death initiated joint consultation by the Departments
are environmental risk factors. Some are natural of Health and Environment about adding
hazards; others are generated by human activ- environment as a key area within the Health of
 Epicanthic Fold 241

the Nation strategy. The first UK Minister of as a result of damage to the cells of the heart
State for Public Health was appointed in 1997 muscle. Some inherited diseases such as GALAC-
with responsibilities for health promotion and TOSAEMIA and PHENYLKETONURIA are the
public-health issues, both generally and within result of deficiencies of certain enzymes.
the NHS. These responsibilities include the Enzymes can be a useful part of treatment for
implementation of the Health of the Nation some disorders. STREPTOKINASE, for example, is
strategy and its successor, Our Healthy Nation. used to treat THROMBOSIS; wound-dressings
The aim is to raise the priority given to human containing papain from the pawpaw fruit this
health throughout government departments, contains protein-digesting enzymes assist in
and to make health and environmental impact the healing process; and pancreatic enzymes can
assessment a routine part of the making, be of value to patients with malabsorption E
implementing and assessing the impact of caused by disorders of the PANCREAS.
policies.
Enzyme-Linked Immunosorbent
Global environmental risks The scope Assay (ELISA)
of many environmental threats to human This is a sensitive method for measuring the
health are international and cannot be regulated quantity of a substance. An antibody to the
effectively on a local, regional or even national substance is prepared along with an ENZYME
basis. One example is the Chernobyl nuclear which binds to the antibody and which can be
reactor accident, which led to a major release of accurately measured using colour changes that
radiation, the effects of which were felt in many occur as a result of the chemical reaction.
countries. Some international action has
already been taken to tackle global environ- Eosinophil
mental problems, but governments should Any cell in the body with granules in its sub-
routinely measure the overall impacts of devel- stance that stain easily with the dye, eosin.
opment on people and their environments and Granulocytes which form about 2 per cent of
link with industry to reduce damage to the the white cells of the blood are eosinophils.
environment. For instance, the effects of global
warming and pollution on health should be Eosinophilia
assessed within an ecological framework if Eosinophilia means an abnormal increase in the
communities are to respond effectively to number of eosinophils (see EOSINOPHIL) in the
potential new global threats to the blood. It occurs in Hodgkins disease (see
environment. LYMPHOMA), in ASTHMA and hay fever, in some
skin diseases, and in parasitic infestation.
Enzyme
A protein that acts as a catalyst for the bodys Ephedrine
metabolic processes. The body contains thou- An alkaloid (see ALKALOIDS) derived from a spe-
sands of enzymes, with each cell producing sev- cies of Ephedra or prepared synthetically. A
eral varieties. The first enzyme was obtained in BRONCHODILATOR, it was once widely used to
a reasonably pure state in 1926. Since then, sev- treat asthma, but has now been superseded by
eral hundred enzymes have been obtained in the much safer (and more effective) selective
pure crystalline form. They are present in the beta-2-adrenoceptor stimulants (see ADRENER-
digestive fluids and in many of the tissues, and GIC RECEPTORS). Ephedrine is a constituent of
are capable of producing in small amounts the several decongestant cold and cough remedies
transformation on a large scale of various com- available to the general public.
pounds. Examples of enzymes are found in the
PTYALIN of saliva and DIASTASE of pancreatic Ephelides
juice which split up starch into sugar; the PEP- The technical term for FRECKLES.
SIN of the gastric juice and the trypsin of pan-
creatic juice which break proteins into simpler Ephelis
molecules and eventually into the constituent See EPHELIDES.
amino acids; and the thrombin of the blood
which causes coagulation. Epi-
The diagnosis of certain disorders can be A prefix meaning situated on or outside of.
helped by measuring the concentrations of
various enzymes in the blood. After a heart Epicanthic Fold
attack (myocardial infarction see HEART, DIS- A vertical skinfold that runs from the upper
EASES OF), raised levels of heart enzymes occur eyelid to the side of the nose. These folds are
 242 Epicondyle

normal in oriental races but uncommon in contributes to the control not only of infectious
others, although babies may have a temporary diseases but also of conditions such as heart dis-
fold that disappears. Folds are present in people ease and cancer. Their distributions in popula-
with DOWNS (DOWN) SYNDROME. tions can provide important pointers to possible
causes. The relation between the environment
Epicondyle and disease is an essential part of epidemiology.
The protuberance above a CONDYLE at the end (See ENVIRONMENT AND HEALTH; PUBLIC
of a bone with an articulating joint for HEALTH.)
example, at the bottom of the humerus, the
bone of the upper arm. Epidermis
E The outer layer of the SKIN, which forms the
Epidemic protective covering of the body.
Epidemic is a term applied to a disease which
affects a large number of people in a particular Epidermophyton
locality at one time. The term is, in a sense, A fungus infection of the skin causing RING-
opposed to ENDEMIC, which means a disease WORM or tinea.
always found in the locality in question. A dis-
ease may, however, be endemic as a rule for Epididymis
example, MALARIA in swampy districts and An oblong body attached to the upper part of
may become at times epidemic, when an each TESTICLE, composed of convoluted vessels
unusually large number of people are affected. and ducts, that connects the VASA EFFERENTIA
The rapid expansion of air travel has extended to the VAS DEFERENS. Sperm cells produced in
the scope for the spread of epidemic and the testis pass along the epididymis, maturing as
endemic disease. they go, to be stored in the seminal vesicles
An epidemic disease is usually infectious until EJACULATION occurs. The epididymis may
from person to person, but not necessarily so be damaged by trauma or infection resulting
since many persons in a locality may simply be sometimes in sterility. Cysts may also occur.
exposed to the same cause at one time; for
example, outbreaks of lead-poisoning are epi- Epidural Anaesthesia
demic in this sense. See ANAESTHESIA.
The conditions which govern the outbreak of
epidemics are poorly understood, but include Epigastrium
infected food supplies, such as drinking water The region lying in the middle of the ABDOMEN
contaminated by waste from people with over the stomach.
CHOLERA or typhoid fever (see ENTERIC FEVER);
milk infected with TUBERCLE bacillus; or fast Epigenetics
food products contaminated with salmonella. The science of how the activity of DNA (deoxy-
The migrations of certain animals, such as rats, ribonucleic acid, which is the fundamental
are in some cases responsible for the spread of genetic material of cells) can be altered semi-
PLAGUE, from which these animals die in great permanently by chemical processes rather than
numbers. Certain epidemics occur at certain by natural MUTATION. Genes contain instruc-
seasons: for example, whooping-cough occurs tions for making proteins. The natural process
in spring, whereas measles produces two epi- of implementing these instructions gene
demics as a rule, one in winter and one in expression can be altered by chemical groups
March. Influenza, the common cold, and other attaching themselves to the chemical bases that
infections of the upper respiratory tract, such as make up a strand of DNA. This, in turn, affects
sore throat, occur predominantly in the winter. the generation of proteins from the genes so
There is another variation, both as regards tagged. Some chemical groups can even stop a
the number of persons affected and the number gene from being expressed. Recently, research in
who die in successive epidemics: the severity of Australia showed that such a chemically
successive epidemics rises and falls over periods induced alteration could be inherited, at least in
of five or ten years. mice. This points to the possibility that
inherited epigenetic characteristics could cause
Epidemiology inherited diseases in the same way that natural
The study of disease as it affects groups of genetic mutations do. These developments sug-
people. Originating in the study of epidemics of gest that epigenetics will be an important part
diseases like CHOLERA, PLAGUE and SMALLPOX, of genetic studies and research. Not all geneti-
epidemiology is an important discipline which cists, however, believe that this developing
 Epilepsy 243

aspect of genetics is so important and this people who have a single seizure, a significant
debate will continue. minority (20 per cent) have no further attacks.

Epiglottis Major (generalised) seizures have a

A leaf-like piece of elastic CARTILAGE covered sudden, often unprovoked onset; the patient
with mucous membrane, which stands upright emits a cry, then falls to the ground, rigid, blue,
between the back of the tongue and the glottis, and then twitching or jerking both sides of the
or entrance to the LARYNX. In the act of swal- body: the tonic-clonic convulsion. Drowsiness
lowing, it prevents fluids and solids from pass- and confusion may last for some hours after
ing off the back of the tongue into the larynx. recovering consciousness. Some experience a
momentary warning (AURA): a smell, or sensa- E
Epiglottitis tion in the head or abdomen, vision, or dj vu.
Acute epiglottitis is a septicaemic illness which
includes an acute inflammatory OEDEMA of the Partial seizures: focal motor (Jackso-
EPIGLOTTIS, due to Haemophilus influenzae. It nian) begin with twitching of the angle of the
progresses very rapidly and a child can be dan- mouth, the thumb, or the big toe. If the seizure
gerously ill or even die within hours of onset. discharge then spreads, the twitching or jerking
Once recognised, however, it is easily and suc- spreads gradually through the limbs. Con-
cessfully treated by immediate transfer to hos- sciousness is preserved unless the seizure spreads
pital for emergency intubation and ventilation to produce a secondary generalised fit. In some
and use of antibiotics and steroids. Fortunately attacks the eyes and head may turn, the arm
it is now very rare as a result of the introduction may rise, and the body may turn, while some
of haemophilus vaccine into the primary vac- patients feel tingling in the limbs.
cination course of infants. (See LARYNGO-
TRACHEO-BRONCHITIS.) Complex partial seizures (temporal
lobe epilepsy) The patient usually appears
Epignathus blank, vacant and may be unable to talk, or may
Maldevelopment of the FETUS in which the mumble or chatter though later they often
deformed remains of one twin are united to the have no memory of this period. They may be
upper jaw of the other. able to carry out complex tasks, taking off
gloves or clothes, and may smack their lips or
Epilation rub repeatedly on one limb (automatisms). A
Removal of hair by the roots. (See DEPILATION.) sense of strangeness supervenes: unreality, or a
feeling of having experienced it all before (dja
Epilepsy vu). There may be a sense of panic. Strange
(See also FIT; SEIZURE.) Epilepsy is the name unpleasant smells and tastes are olfactory and
given to any condition in which a person suffers gustatory hallucinations. The visual hallucin-
repeated fits or seizures. It is present in one in ations evoke complex scenes. An initial rising
200 (05 per cent) of the population and up to sense of warmth or discomfort in the stomach,
5 per cent of all children will have had a fit by or speeding-up of thoughts are common psy-
the age of 12, although most of these are harm- chomotor symptoms. All these strange symp-
less accompaniments of an acute feverish toms are brief, disappearing within a few sec-
illness. onds or up to 34 minutes.
It is a recurrent and paroxysmal disorder
starting suddenly and ceasing spontaneously Minor seizures (petit mal) Attacks start
due to occasional sudden excessive rapid and in childhood. They last a few seconds. The
local discharge of the nerve cells in the grey child ceases what he or she is doing, stares,
matter (cortex) of the BRAIN. Epilepsy always looks a little pale, and may flutter the eyelids.
arises in this way from the brain, but its origin is The head may drop forwards. Attacks are
often of microscopic size. It is diagnosed by the commonly provoked by overbreathing. The
clinical symptoms based on the observations of child and parents may be unaware of the attacks
witnesses. Its cause can sometimes be estab- just daydreaming. Major fits develop in one-
lished by laboratory tests, and brain scanning. third of subjects. By contrast with other types of
Fits can be the first sign of a tumour, or follow a epilepsy, the ELECTROENCEPHALOGRAM (EEG) is
stroke, brain injury or infection, but in the large diagnostic.
majority no underlying cause is found so-
called idiopathic epilepsy. Precautions Children with epilepsy should
A single epileptic fit is not epilepsy. Of those take normal school exercises and games, and
 244 Epiloia

can swim under supervision. Adults must avoid Patients who have an epileptic seizure should
working at heights, with exposed dangerous not be restrained or have a gag or anything else
machinery, and driving vehicles on public placed in their mouths; nor should they be
roads. Current legislation allows driving after moved unless in danger of further injury. Any
two years of complete freedom from attacks tight clothing around the neck should be loos-
during waking hours; those who for more than ened and, when the seizure has passed, the per-
three years have had a history of attacks only son should be placed in the recovery position to
while asleep may also drive. facilitate a return to consciousness (see APPEN-
DIX 1: BASIC FIRST AID).
Treatment identifies, and avoids where pos- Patients with epilepsy and their relatives can
E sible, any factors (such as shortage of sleep or obtain further advice and information from the
excessive fluids) which aggravate or trigger British Epilepsy Association or Epilepsy Action
attacks. If fits are very infrequent, treatment Scotland.
may not be recommended. However, frequent
fits may be embarassing, may cause injury or Epiloia
may cause long-term brain damage so treat- See TUBEROUS SCLEROSIS.
ment is advisable. Anti-epileptic drugs are usu-
ally necessary for several years under medical Epiphora
supervision. Carbamazepine and sodium val- Inadequate drainage of tears in the eyes with the
proate are the most frequently prescribed. The result that they overflow down the cheeks. The
dose is governed by the degree of control of fits condition is caused by an abnormality of the
and sometimes drug levels can be monitored by tear ducts which drain away the normal secre-
blood tests to check on dosage. Strict adherence tions that keep the eyeball moist (see EYE).
to the drug schedule gives a reasonable chance
of total suppression of fits, especially in younger Epiphysis
patients whose fits have started recently. The See BONE Growth of bones.
table summarises anticonvulsant drugs in use.
Interactions can occur between anti-epileptics Epiphysitis
and, if drug treatment is changed, the patient Inflammation of an epiphysis (see BONE
needs careful monitoring. In particular, abrupt Growth of bones).
withdrawal of a drug should be avoided as this
may precipitate severe rebound seizures. Epirubicin
Indications A cytotoxic anthracycline antibiotic drug used
First-choice drugs: in the treatment of solid tumours, acute LEU-
Ethosuximide PM, JME KAEMIA and LYMPHOMA. It is related structur-
Phenobarbitone M, P ally to DOXORUBICIN and is given intravenously,
Phenytoin M, P, CP and by instillation into the URINARY BLADDER
Carbamazepine M, P, CP to treat bladder cancer under specialist
Valproate M, PM, JME supervision.
Second-line drugs:
Primidone M, P, CP
Clobazam M, CP
Episclera
Vigabatrin M, P, CP The most superficial layer of the sclera of the
Lamotrigine M, P, CP EYE. It sometimes becomes inflamed (episcleri-
Gabapentin M, P, CP tis) but the condition usually clears without
Topirimate P treatment.

M = major generalised tonic-clonic; P = partial or Episiotomy

focal; CP = complex partial (temporal lobe); PM = A cut made in the PERINEUM to enlarge the
petit mal; JME = juvenile myoclonic epilepsy. vaginal opening and facilitate childbirth during
Anticonvulsant drugs a difficult birth when the babys head (or in a
breech delivery, the buttocks) is making slow
As all anticonvulsant drugs have an effect on progress down the birth canal, or when forceps
the brain, it is not surprising that there may be have to be applied. (See PREGNANCY AND
side-effects, especially inolving alertness or LABOUR.)
behaviour. In each case careful assessment is
necessary for doctor and patient to agree on the Epispadias
best compromise between stopping fits and An inherited abnormality of the PENIS in which
avoiding ill-effects of medication. the opening of the URETHRA is on the upper
 Ergocalciferol 245

surface instead of at the end of the organ. Surgi- infectious MONONUCLEOSIS. It is similar to the
cal correction carried out in infancy has a high viruses that cause herpes and is associated with
success rate. BURKITTS LYMPHOMA. It has been suggested as
precipitating some attacks of MYALGIC
Epistasis ENCEPHALOMYELITIS (ME), also known as
(1) Stopping a flow or discharge of, for CHRONIC FATIGUE SYNDROME (CFS).
example, blood from a wound. (2) In genetics
the term describes a type of gene action (see Eptifibitide
GENES) where a gene is able to block the action An antiplatelet drug, best given under the
of another one. supervision of a specialist. It inhibits the aggre-
gation of PLATELETS in the blood that occurs in E
Epistaxis THROMBUS formation, and is used with HEP-
Bleeding from the nose. (See HAEMORRHAGE.) ARIN and ASPIRIN to prevent early myocardial
infarction (heart attack see HEART, DISEASES
Epithelioma OF) in patients with unstable ANGINA PECTORIS.
Epithelioma is a tumour of malignant nature
arising in the EPITHELIUM covering the surface Epulis
of the body. (See CANCER.) Epulis is a term applied to any tumour con-
nected with the jaws. (See MOUTH, DISEASES
Epithelium OF.)
Epithelium is the cellular layer which forms the
epidermis on the skin, covers the inner surface Equine Oestrogens
See OESTROGENS.
of the bowels, and forms the lining of ducts and
hollow organs, like the bladder. It consists of
one or more layers of cells which adhere to one
Erbs Paralysis
Erbs paralysis is a form of paralysis of the arm
another, and is one of the simplest tissues of the
due to stretching or tearing of the fibres of the
body. It is of several forms: for example, the
brachial nerve plexus. Such damage to the bra-
epidermis is formed of scaly epithelium, the
chial plexus may occur during birth, especially
cells being in several layers and more or less
when the baby is unusually large, and it is
flattened. (See SKIN.) The bowels are lined by a
found that the arm lies by the side of the body
single layer of columnar epithelium, the cells
with elbow extended, forearm pronated, and
being long and narrow in shape. The air pas-
the fingers flexed. The infant is unable to raise
sages are lined by ciliated epithelium: that is to
the arm.
say, each cell is provided with flagellae (lashes)
which drive the fluid upon the surface of the ERCP
passages gradually upwards. See ENDOSCOPIC RETROGRADE CHOLANGIO-
PANCREATOGRAPHY (ERCP).
Epizotic
Any disease in animals which diffuses itself Erection
widely. The term corresponds to the word EPI- The rigid state of the PENIS when it responds to
DEMIC as applied to human beings. In plague, sexual stimulus. An erection is necessary for
for example, an epizotic in rats usually pre- effective penetration of the VAGINA. As a result
cedes the epidemic in human beings. of sexual arousal, the three cylinders of erectile
tissue in the penis become engorged with
Eponym blood, lengthening, raising and hardening the
A species, structure or disorder named after a penis. Muscles surrounding the blood vessels
particular individual, customarily the one who contract and retain the blood in the penis. Erec-
first described or discovered it. The use of tions also occur during sleep and in young boys.
eponyms has been widespread in medicine, but Inability to have or maintain an erection is one
more descriptive and so more practical cause of IMPOTENCE (see also SILDENAFIL
terms are replacing them. CITRATE).

Epsom Salts Erg-

The popular name for magnesium sulphate, A prefix indicating activity or work.
which was used as a saline purgative.
Ergocalciferol
Epstein Barr Virus A combination of CALCIFEROL and vitamin D2
The virus that causes glandular fever or (see APPENDIX 5: VITAMINS) given to prevent or
 246 Ergometrine

cure RICKETS, a deficiency disorder caused by example, the mouth, breasts and genitals
the lack of calcium and vitamin D in the diet. which, when stimulated, result in the indi-
viduals sexual arousal.
Ergometrine
An active constituent of ergot, it has a powerful Erosion
action in controlling the excessive bleeding Erosion means a process of gradual wearing
from the UTERUS which may occur after child- down of structures in the body. The term is
birth. The official British Pharmacopoeia prep- applied to the effect of tumours, when they
aration is ergometrine maleate. cause destruction of tissue in their neighbour-
hood without actually growing into the latter:
E Ergonomics for example, an ANEURYSM may erode bones in
A broad science involving the application of its neighbourhood. The term is also applied to
psychological and physiological principles to minute ulcers for example, erosions of the
the study of human beings in relation to their stomach, caused by extreme acidity of the gas-
work and working surroundings. It includes the tric juice.
design of buildings, machinery, vehicles, and
anything else with which people have contact in Dental erosion is the loss of tooth sub-
the course of their work. stance due to a cause other than decay or
trauma. This is usually as a result of the pres-
Ergosterol ence of acid; for example, frequent vomiting
A sterol found in yeasts and fungi and in plant or the excessive intake of citrus fruits. The
and animal fat. Under the action of sunlight teeth appear very smooth and later develop
or ultraviolet rays it produces vitamin D2. The saucer-shaped depressions.
substance produced in this way is known as
calciferol, and is used for the prevention and Eroticism
cure of RICKETS and OSTEOMALACIA. A similar The emotional nature and characteristics of
change in the ergosterol of the skin is pro- sexual arousal. This may occur as a result of
duced when the body is freely exposed to sun- visual, auditory or physical stimuli and also as a
light. Calciferol is probably not so active as, result of sexually oriented memories or
and differs chemically from, the vitamin D imaginings.
occurring in fish-liver oils. (See APPENDIX 5:
VITAMINS.) Eructation
Eructation, or belching, is the sudden escape of
Ergot Poisoning gas or of portions of half-digested food from the
Ergot poisoning, or ergotism, occasionally stomach up into the mouth.
results from eating bread made from rye
infected with the fungus, Claviceps purpurea. Eruption
Several terrible epidemics (St Anthonys Fire), Eruption, or rash, means an outbreak, in a scat-
characterised by intense pain and hallucin- tered form, upon the surface of the skin. The
ations, occurred in France and Germany during skin is usually raised and red, or it may be
the Middle Ages (see ERYSIPELAS). Its symptoms covered with scales, or crusts, or vesicles con-
are the occurrence of spasmodic muscular con- taining fluid. Eruptions differ in appearance:
tractions, and the gradual production of gan- for example, the eruption of MEASLES is always
grene in parts like the fingers, toes and tips of distinguishable from that of CHICKENPOX. But
the ears because of constriction of blood vessels the same disease may also produce different
and therefore the blood supply. eruptions in different people; or in the same
person in different states of health; or even on
Ergotamine different parts of the body at one time.
One of the alkaloids in ergot. In the form of Eruptions may be acute or chronic. Most of
ergotamine tartrate it is usually given orally to the acute eruptions belong to the exanthemata
treat MIGRAINE, but treatment carries a risk and (see EXANTHEM): that is, they are bright in col-
should be medically supervised. our and burst out suddenly like a flower. These
are the eruptions of SCARLET FEVER, measles,
Ergotism German measles (see RUBELLA), SMALLPOX and
See ERGOT POISONING. chickenpox. In general, the severity of these dis-
eases can be measured by the amount of erup-
Erogenous tion. Some eruptions are very transitory, like
A term to describe those parts of the body for nettle-rash, appearing and vanishing again in
 Erythroderma 247

the course of a few hours. (See also SKIN, DIS- mucous membranes of the eyes, mouth and
EASES OF.) genitalia may be involved.

Erysipelas Erythema infectiosum is an acute con-

A streptococcal infection (see STREPTOCOCCUS) tagious disease of children caused by a parvo-
of the skin characterised by an acute onset with virus (see PARVOVIRUSES). In young children a
fever, malaise and a striking, usually unilateral, bright erythema of the face gives a slapped
rash (see ERUPTION) almost always on a lower cheek appearance.
leg or the face. Shivering, local pain and ten-
derness are associated with a sharply defined, Erythrasma
spreading, bright red swollen zone of skin A superficial mild infection of the skin caused
E
inflammation. On the leg, blistering and PUR- by CORYNEBACTERIA. It produces pink or
PURA may follow. The bacteria enter the skin slightly brown flaky areas of skin usually on the
through a fissure in a toe cleft (often associated upper inner thighs or axillae. Toe clefts may be
with tinea pedis [RINGWORM]) or via a crack in affected with thickened, white, macerated skin.
the skin behind an ear or in a nostril. The affected areas fluoresce coral pink under
ultraviolet light. CLOTRIMAZOLE or KETOCO-
Treatment PENICILLIN in full dosage should NAZOLE cream clears the rash rapidly. Very
be given orally for ten days. In those allergic to extensive erythrasma responds to oral ERYTH-
penicillin, ERYTHROMYCIN can be substituted. ROMYCIN given for seven days.
Recurrent attacks are common and may cause
progressive lymphatic damage leading to Erythroblastosis Fetalis
chronic OEDEMA. Such recurrences can be pre- See HAEMOLYTIC DISEASE OF THE NEWBORN.
vented by long-term prophylactic oral
penicillin. Erythroblasts
A series of nucleated cells in the bone marrow
Erythema that go through various stages of development
Redness of the skin due to dilatation of dermal
until they form ERYTHROCYTES. They may
blood vessels. It may be transient or chronic,
appear in the blood in certain diseases.
localised or widespread, and it can be blanched
by pressure. Erythema may be caused by exces-
sive exposure to heat or ultraviolet light, or by
Erythrocytes
The biconcave red blood cells that carry oxygen
inflammation of the skin due to infection,
from the lungs to the tissues, and return carbon
DERMATITIS, and various allergic reactions for
dioxide (see also RESPIRATION). They have an
example, to drugs. It may be emotional (e.g. as
excess of membrane, some of which may be lost
in flushing), mediated by the autonomic ner-
in various disorders, as a result of which they
vous system.
become progressively more spherical and rigid.
Erythema ab igne is a fixed redness of the Erythrocytes, which have no nuclei, are formed
skin caused by chronic exposure to heat from a during ERYTHROPOEISIS from ERYTHROBLASTS
domestic fire or radiator. in the BONE MARROW, and each mm3 of
blood contains 5 million of them. They are by
Erythema pernio (See CHILBLAIN.) Redness far the largest constituent among the blood cells
induced by spasm of the skin arterioles due to and they contain large amounts of the oxygen-
cold. It affects the hands, feet or calves in win- carrier HAEMOGLOBIN. They have a life of
ter. The red swollen areas are cooler than about 120 days after which they are absorbed
normal. by macrophages (see MACROPHAGE), the bloods
scavenging cells. Most components of the
Erythema nodosum A singular pattern of erythrocytes, including the red pigment
red, tender nodules occurring on the shins, haemoglobin, are re-used, though some of the
often lasting several weeks. It may be caused by pigment is broken down to the waste product
a streptococcal throat infection, primary tuber- BILIRUBIN.
culosis, SARCOIDOSIS, or may be drug-induced.
Erythrocyte Sedimentation Rate
Erythema multiforme is an acute allergic See ESR.
eruption of the extremities characterised by cir-
cular areas of erythema, purpura and blistering, Erythroderma
which resolve over two or three weeks, caused A rare inflammation of the skin which causes
by infections or drugs. In severe forms the universal itching. The skin is red, thickened
 248 Erythromelalgia

and scaly. It is also called generalised exfolia- Erythropoeisis

tive dermatitis (see SKIN, DISEASES OF). It may The process by which ERYTHROCYTES or red
complicate chronic eczema (see DERMATITIS) blood cells are produced. The initiating cell is
or PSORIASIS, particularly in men, in the sec- the haemopoietic stem cell from which an iden-
ond half of life. It may also result from tifiable proerythroblast develops. This goes
HYPERSENSITIVITY to a drug, such as gold through several stages as a normoblast before
injections used in RHEUMATOID ARTHRITIS. losing its nucleus to become an erythrocyte.
Rarely, it may be a manifestation of T-cell This process takes place in the blood-forming
LYMPHOMA. bone-marrow tissue.
Universal inflammation of the skin may
E cause heart failure, particularly in elderly people Erythropoietin
with pre-existing heart disease. It may lead to The protein, produced mainly in the kidney,
HYPOTHERMIA due to excessive heat loss from that is the major stimulus for the production of
the skin and protein deficiency caused by the ERYTHROCYTES, or red blood corpuscles. It is
shedding of large quantities of skin scales con- used when treating ANAEMIA dure to end-stage
taining keratin. Rarely, these complications can kidney failure and in premature newborns with
be fatal. anaemia. (See also BLOOD.)

Treatment depends on the cause, but in Eschar

eczematous erythroderma, oral CORTICO- Hard adherent crust caused by tissue killed by
STEROIDS (PREDNISOLONE) in full dosage may heat, chemicals or disease.
be needed.
Escherichia
Erythromelalgia The generic name for the group of gram-
A condition in which the fingers or toes, or negative, usually motile, rod-shaped BACTERIA
even larger portions of the limbs, become pur- that can ferment CARBOHYDRATE. They occur
ple and bloated in appearance, and very pain- naturally in the intestines of humans and some
ful. In people suffering from the condition animals. E. coli, which ferments lactose, is not
which is not a common one the attacks come normally harmful but some varieties, particu-
and go, being worse in summer (unlike chil- larly E. coli O157, cause gastrointestinal infec-
blains), and worse on exertion or when the tions which may be severe in old people. E. coli
affected parts are warmed or allowed to hang is also used in laboratory experiments for gen-
down. The condition may appear without etic and bacteriological research.
apparent cause, but is often associated with vas-
cular diseases, such as HYPERTENSION and Eserine
POLYCYTHAEMIA VERA. It aso occurs in associ- Another name for PHYSOSTIGMINE.
ation with certain diseases of the central ner-
vous system, and in cases of metallic poisoning Esmarchs Bandage
(e.g. arsenic, mercury and thallium). Treatment A rubber bandage which is applied to a limb
is unsatisfactory but aspirin provides sympo- before surgery from below upwards, in order to
matic relief. drive blood from the limb. The bandage is
removed after an inflated pneumatic TOURNI-
Erythromycin QUET has been placed round the limb; the
One of the MACROLIDES, it has an antibacterial operation can then proceed.
spectrum similar, but not identical, to that of
penicillin. The drug is a valuable alternative for ESP
patients who are allergic to penicillin. Erythro- See EXTRASENSORY PERCEPTION (ESP).
mycin is used for respiratory infections, includ-
ing spread within a family of WHOOPING- ESR
COUGH, and also CHLAMYDIA, LEGIONNAIRES The ESR or erythrocyte sedimentation rate is a
DISEASE, SYPHILIS and enteritis caused by CAM- test that measures the rate at which red blood
PYLOBACTER. It is also used with neomycin cells settle out of suspension in blood PLASMA.
when preparing for bowel surgery. Though In certain diseases, such as infection and malig-
often active against penicillin-resistant nancy, the amount of proteins in the plasma
staphylococci, these bacteria are now sometimes increases; the result is that red cells settle out
resistant to erythromycin. The drug may be more quickly and this test is used to show
given orally, intravenously or topically (for whether inflammation is present and, to some
acne). extent, its severity.
 Ethics 249

Essential Amino Acids used as an emergency, short-term treatment for

See INDISPENSABLE AMINO ACIDS. severe bleeding until blood for transfusion is
available. Plasma substitutes must be used with
Essential (Benign) Hypertension caution in patients who have heart disease or
See HYPERTENSION. impairment of their kidney function. Patients
should be monitored for hypersensitivity reac-
Essential Fatty Acids tions and for changes in their BLOOD PRESSURE
Three acids arachidonic, linolenic and (see SHOCK).
tinoleic which are essential for life, but which
the body cannot produce. They are found in Ethics
natural vegetable and fish oils and their func- Within most cultures, care of the sick is seen as E
tions are varied. EFAs have a vital function in entailing special duties, codified as a set of
fat metabolism and transfer and they are also moral standards governing professional prac-
precursors of PROSTAGLANDINS. tice. Although these duties have been stated and
interpreted in differing ways, a common factor
Ester is the awareness of an imbalance of power
An organic compound formed from an alcohol between doctor and patient and an acknow-
and an acid by the removal of water. ledgement of the vulnerability of the sick
person. A function of medical ethics is to coun-
Ethacrynic Acid teract this inevitable power imbalance by
A potent diuretic, with a rapid onset, and a encouraging doctors to act in the best interests
short duration (46 hours), of action. (See of their patients, refrain from taking advantage
THIAZIDES; DIURETICS.) of those in their care, and use their skills in a
manner which preserves the honour of their
Ethambutol profession. It has always been accepted, how-
Ethambutol is a synthetic drug, often included ever, that doctors cannot use their knowledge
in the treatment regimen of TUBERCULOSIS indiscriminately to fulfil patients wishes. The
when the infection is thought to be resistant to deliberate ending of life, for example, even at a
other drugs. The main side-effects are visual patients request, has usually been seen as alien
disturbances, chiefly loss of acuity and colour to the shared values inherent in medical ethics.
blindness. Such toxic effects are more common It is, however, symptomatic of changing con-
when excessive dosages are used, or the patient cepts of ethics and of the growing power of
has some renal impairment, in which case the patient choice that legal challenges have been
drug should be avoided as it should be in mounted in several countries to the prohibition
young children. of EUTHANASIA. Thus ethics can be seen as
regulating individual doctor-patient relation-
Ethanol ships, integrating doctors within a moral com-
Ethanol is another name for ethyl alcohol. (See munity of their professional peers and reflecting
ALCOHOL.) societal demands for change.
Medical ethics are embedded in cultural
Ether values which evolve. Acceptance of abortion
A colourless, volatile, highly inflammable within well-defined legal parameters in some
liquid, formed by the action of sulphuric acid jurisdictions is an example of how society influ-
on alcohol. Ether boils below body temperature ences the way in which perceptions about eth-
and therefore rapidly evaporates when sprayed ical obligations change. Because they are often
over the skin. Dissolving many substances such linked to the moral views predominating in
as fats, oils and resins better than alcohol or society, medical ethics cannot be seen as
water, it is used in the preparation of many embodying uniform standards independent of
drugs. Formerly used as an anaesthetic, it has cultural context. Some countries which permit
been replaced by safer and more efficient drugs. capital punishment or female genital mutilation
(FGM see CIRCUMCISION), for example,
Etherified Starch expect doctors to carry out such procedures.
Along with DEXTRAN and GELATIN, this is a Some doctors would argue that their ethical
substance with a large molecular structure used obligation to minimise pain and suffering
to treat shocked patients with burns (see BURNS obliges them to comply, whereas others would
AND SCALDS) or SEPTICAEMIA in order to expand deem their ethical obligations to be the
and maintain their blood volume. Like other complete opposite. The medical community
plasma substitutes, this form of starch can be attempts to address such variations by establish-
 250 Ethics

ing globally applicable ethical principles solving, the four principles require interpret-
through debate within bodies such as the World ation. Enduring ethical precepts such as the
Medical Association (WMA) or World Psychi- obligation to benefit patients and avoid harm
atric Association (WPA). Norm-setting bodies (beneficence and non-maleficence) may be dif-
increasingly reflect accepted concepts of human ferently interpreted in cases where prolongation
rights and patient rights within professional of life is contrary to a patients wishes or where
ethical codes. sentience has been irrevocably lost. In such
Practical changes within society may affect cases, treatment may be seen as constituting a
the perceived balance of power within the harm rather than a benefit.
doctor-patient relationship, and therefore have The importance accorded to ethics in daily
E an impact on ethics. In developed societies, for practice has undergone considerable develop-
example, patients are increasingly well ment in the latter half of the 20th century.
informed about treatment options: media such From being seen mainly as a set of values passed
as the Internet provide them with access to spe- on from experienced practitioners to their stu-
cialised knowledge. Social measures such as a dents at the bedside, medical ethics have
well-established complaints system, procedures increasingly become the domain of lawyers,
for legal redress, and guarantees of rights such academic philosophers and professional ethi-
as those set out in the NHSs Patients Charter cists, although the role of experienced practi-
appear to reduce the perceived imbalance in the tioners is still considered central. In the UK,
relationship. Law as well as ethics emphasises law and medical ethics increasingly interact.
the importance of informed patient consent Judges resolve cases on the basis of established
and the often legally binding nature of medical ethical guidance, and new ethical guid-
informed patient refusal of treatment. Ethics ance draws in turn on common-law judgements
reflect the changing relationship by emphasis- in individual cases. The rapid increase in spe-
ing skills such as effective communication and cialised journals, conferences and postgraduate
generation of mutual trust within a doctor- courses focused on ethics is testimony to the
patient partnership. ever-increasing emphasis accorded to this area
A widely known modern code is the WMAs of study. Multidisciplinary practice has stimu-
International Code of Medical Ethics which seeks lated the growth of the new discipline of
to provide a modern restatement of the health-care ethics which seeks to provide uni-
Hippocratic principles. formity across long-established professional
Traditionally, ethical codes have sought to boundaries. The trend is to set common stand-
establish absolutist positions. The WMA code, ards for a range of health professionals and
for example, imposes an apparently absolute others who may have a duty of care, such as
duty of confidentiality which extends beyond hospital chaplains and ancillary workers. Since
the patients death. Increasingly, however, ethics a primary function of ethics is to find reason-
are perceived as a tool for making morally able answers in situations where different
appropriate decisions in a sphere where there is interests or priorities conflict, managers and
rarely one right answer. Many factors such as health-care purchasers are increasingly seen as
current emphasis on autonomy and the indi- potential partners in the effort to establish a
vidual values of patients; awareness of social and common approach. Widely accepted ethical
cultural diversity; and the phenomenal advance values are increasingly applied to the previously
of new technology which has blurred some unacknowledged dilemmas of rationing scarce
moral distinctions about what constitutes a resources.
person have contributed to the perception In modern debate about ethics, two import-
that ethical dilemmas have to be resolved on a ant trends can be identified. As a result of the
case-by-case basis. increasingly high profile accorded to applied
An approach adopted by American ethicists ethics, there is a trend for professions not previ-
has been moral analysis of cases using four fun- ously subject to widely agreed standards of
damental principles: autonomy, beneficence, behaviour to adopt codes of ethical practice.
non-maleficence and justice. The four prin- Business ethics or the ethics of management are
ciples provide a useful framework within which comparatively new. At the same time, there is
ethical dilemmas can be teased out, but they are some debate about whether professionals, such
criticised for their apparent simplicity in the as doctors, traditionally subject to special eth-
face of complex problems and for the fact that ical duties, should be seen as simply doing a job
the moral imperatives implicit in each principle for payment like any other worker. As some
often conflict with some or all of the other doctors perceive their power and prestige
three. As with any other approach to problem- eroded by health-care managers deciding on
 Ethylene 251

how and when to ration care and pressure for Ethics Advisory Committees, which debate dif-
patients to exercise autonomy about treatment ficult patient cases. Most are attached to special-
decisions, it is sometimes argued that realistic ised health facilities such as fertility clinics or
limits must be set on medical obligations. A childrens care facilities. The 1990s have seen a
logical implication of patient choice and rejec- greatly increased interest in professional ethics
tion of medical paternalism would appear to be and the establishment of many new ethics
a concomitant reduction in the freedom of doc- committees, including some like that of the
tors to carry out their own ethical obligations. National Council for Hospice and Specialist
The concept of conscientious objection, Palliative Care Services which cross professional
incorporated to some extent in law (e.g. in rela- boundaries. Guidance on professional and eth-
tion to abortion) ensures that doctors are not ical standards is produced by these new bodies E
obliged to act contrary to their own personal or and by the well-established ethics committees
professional values. of regulatory or representative bodies, such as
the medical and nursing Royal Colleges, the
Ethics Committees General Medical Council, United Kingdom
(In the USA, Institutional Review Boards.) Central Council for Nursing, Midwifery and
Various types of ethics committee operate in the Health Visiting, British Medical Association (see
UK, fulfilling four main functions: the moni- APPENDIX 8: PROFESSIONAL ORGANISATIONS)
toring of research; debate of difficult patient and bodies representing paramedics and profes-
cases; establishing norms of practice; and pub- sions supplementary to medicine. Their guid-
lishing ethical guidance. ance ranges from general codes of practice to
The most common Local Research Ethics detailed analysis of single topics such as
Committees (LRECs) have provided a moni- EUTHANASIA or surrogacy.
toring system of research on humans since the LRECs are now supervised by a central body
late 1960s. Established by NHS health author- COREC (www.corec.gov.org.uk).
ities, LRECs were primarily perceived as exer-
cising authority over research carried out on Ethinylestradiol
NHS patients or on NHS premises or using A highly active oestrogen about 20 times
NHS records. Their power and significance, more active than STILBOESTROL; it is active
however, developed considerably in the 1980s when given by mouth. (See OESTROGENS.)
and 90s when national and international guid-
ance made approval by an appropriately consti- Ethmoid
tuted ethics committee obligatory for any A bone in the base of the SKULL which separates
research project involving humans or human the cavity of the nose from the membranes of
tissue. The work of LRECs is supplemented by the brain. It is a spongy bone with numerous
so-called independent ethics committees usu- cavities or sinuses.
ally set up by pharmaceutical companies, and Suppuration in the ethmoidal sinuses is
since 1997 by multicentre research ethics sometimes responsible for inflammation in
committees (MRECs). An MREC is respon- neighbouring parts such as the eye.
sible for considering all health-related research Ethosuximide
which will be conducted within five or more A drug used in the treatment of the form of
locations. LRECs have become indispensable to EPILEPSY known as petit mal.
the conduct of research, and are doubtless
partly responsible for the lack of demand in the Ethyl Chloride
UK for legislation governing research. A pleth- A flammable, colourless liquid that is extremely
ora of guidelines is available, and LRECs which volatile, and rapidly produces freezing of a sur-
fail to comply with recognised standards could face when sprayed upon it. Now occasionally
incur legal liability. They are increasingly gov- used to deaden pain for small and short oper-
erned by international standards of practice. In ations, ethyl chloride was once used as an inhal-
1997, guidelines produced by the International ant general anaesthetic for brief operations, and
Committee on Harmonisation of Good Clin- to induce ANAESTHESIA in patients in whom the
ical Practice (ICH-GCP) were introduced into anaesthesia is subsequently to be maintained by
the UK. These provide a unified standard for some other anaesthetic such as nitrous oxide or
research conducted in the European Union, ether.
Japan and United States to ensure the mutual
acceptance of clinical data by the regulatory Ethylene
authorities in these countries. A colourless, flammable gas occasionally used as
Other categories of ethics committee include an inhalant anaesthetic.
 252 Ethyloestrenol

Ethyloestrenol sterile. A male castrated before puberty will

See ANABOLIC STEROIDS. have a feminine appearance and under-
developed secondary sexual characteristics. The
Etidronate term was historically used to describe boys, cas-
Also known as disodium etidronate, this is one trated to make them suitable for working in
of a group of substances called biphosphates harems, or boy singers, castrated to retain their
used mainly to treat PAGETS DISEASE OF BONE. higher-register voices (castrati singers).
The drug is given orally and, when combined
with calcium carbonate (Didrone), it is used Euphoria
to treat osteoporosis (see under BONE, DISORDERS A feeling of well-being. This may occur nor-
E OF) and to prevent bone loss in postmenopausal mally; for instance, when someone has passed
women, especially if hormone replacement an examination. In some neurological or psy-
therapy (HRT see under MENOPAUSE) is not chiatric conditions, however, patients may have
appropriate. an exaggerated and quite unjustified feeling of
euphoria. This is then a symptom of the under-
Etiology lying condition. Euphoria may also be drug-
Etiology, or AETIOLOGY, means the group of induced by drugs of addiction or by thera-
conditions which form the cause of any disease. peutic drugs such as CORTICOSTEROIDS.

Etomidate Euphoriants
An intravenous agent for inducing general Drugs which induce a state of EUPHORIA or
ANAESTHESIA prior to surgery or other pro- well-being.
cedures that require patients to be unconscious.
When the drug is injected intravenously, pain Eustachian Tubes
sometimes occurs, but this can be minimised by The passages, one on each side, leading from
premedication with an opioid analgesic (see the throat to the middle ear. Each is about 38
ANALGESICS). mm (1 inches) long and is large at either end,
though at its narrowest part it only admits a fine
Eu- probe. The tubes open widely in the act of swal-
A prefix meaning satisfactory or beneficial. lowing or yawning. The opening into the throat
is situated just behind the lower part of the
Eucalyptus nose, so that a catheter can be passed through
Eucalyptus (Eucalyptus globulus) is a tree, ori- the corresponding nostril into the tube for
ginally a native of Australia and now grown all inflation of the middle ear. (See also EAR; NOSE.)
over the world. Its important constituent, oil of
eucalyptus, is an oil of pleasant smell and spicy Euthanasia
taste, which is obtained by distillation from the Literally meaning the procuring of an easy and
leaves of the tree. The oil may be used as a painless death, euthanasia (or mercy killing)
disinfectant and deodorant. has come to be understood as a deliberate act or
omission whose primary intention is to end
Eugenics another persons life. The qualifiers voluntary,
The study and cultivation of conditions that involuntary and non-voluntary are used to
may improve the human race, in particular the indicate the degree of patient involvement in
detection and elimination of genetic disease. the decision. Much debate has centred on
whether individuals should be entitled to man-
Eukaryote age their own death or appoint others to do so
A cell that has a NUCLEUS bounded by a mem- for them (voluntary euthanasia). UK public-
brane and with chromosomes containing DNA, opinion surveys appear to indicate substantial
RNA and proteins. The cell divides by MITOSIS support for such a proposal but this partly
and also contains MITOCHONDRIA. Animals, reflects the way in which the issue is broached.
plants and cellular organisms made up of this Predictably, if the choice is portrayed as one
type of cell are included in the biological between euthanasia and an inevitably drawn-
superkingdom of Eukaryote. out, painful or distressing death, many agree
that competent, terminally ill patients who ask
Eunuch for euthanasia should be helped to die. Difficult
A man whose testes (see TESTICLE) have been issues arise, however, when attempts are made
removed or seriously damaged so that he is to set limits and safeguards. This has generally
unable to produce male hormones and thus is been seen as a major stumbling block to any
 Evolution 253

proposal to change the law prohibiting eutha- Evidence

nasia in the UK. Such pragmatic rather than See EVIDENCE-BASED MEDICINE.
ethical or legal arguments were a key feature of
the conclusions of the House of Lords Select Evidence-Based Medicine
Committee on Medical Ethics in 1994. There The process of systematically identifying,
has also been much debate about whether appraising and using the best available research
euthanasia should attract a lesser penalty than findings, integrated with clinical expertise, as
other forms of murder which carry a manda- the basis for clinical decisions about individual
tory life sentence. Nevertheless, in the UK, kill- patients. The aim is to encourage clinicians,
ing a person intentionally is still classified as health-service managers and consumers of
murder, even if that person consents to the health care to make decisions, taking account of
E
killing. the best available evidence, on the likely con-
Most of the detailed information available sequences of alternative decisions and actions.
about the practice of euthanasia comes from the Evidence-based medicine has been developing
Netherlands, where court rulings in the 1970s internationally for the past 25 years, but since
and 1980s began to permit voluntary eutha- around 1990 its development has accelerated.
nasia under certain circumstances (although The International COCHRANE COLLABORATION
both euthanasia and assisted suicide remain finds and reviews relevant research. Several
technically illegal). The difficulty of maintain- other centres have been set up to look at the
ing limits was highlighted in 19945 when it clinical application of research results, includ-
became clear that a small percentage of Dutch ing the Centre for Evidence-Based Medicine in
patients undergoing euthanasia had previously Oxford.
expressed an interest but not specifically
requested it (involuntary euthanasia) or had no Evisceration
known desire for it and may have been opposed Extrusion of the abdominal VISCERA or internal
to it (non-voluntary euthanasia). The relevance organs, usually as the result of serious injury.
of terminal illness and physical suffering was (Usually described as disembowelment when
tested in Holland in 1994 when a patient deliberately carried out by one person on
received euthanasia who was not physically ill another.) In surgery the term refers to part-
and subject to mental rather than physical suf- removal of the viscera, and in OPHTHALMOL-
fering. Nevertheless, Dutch doctors risk pros- OGY it is an operation to remove the contents of
ecution if they fail to follow rules of careful the eyeball (see also EYE).
conduct when carrying out euthanasia or
assisted suicide. (See also ETHICS; SUICIDE.) Evolution
An uninterrupted process of change from one
Euthyroid condition, form or state to another. In bio-
The descriptive term for a person with a nor- logical evolution, all varieties of living things are
mally functioning THYROID GLAND, or some- seen as having developed by inheritable, incre-
one who has had successful treatment for an mental changes from unicellular structures to
underactive (hypothyroid) or overactive (hyper- complex organisms such as humankind.
thyroid) gland. Although the likelihood of some form of evolu-
tion had been postulated by scientists in the late
Evacuant 18th and early 19th centuries, the prime
Evacuant is a name for a purgative medicine (see contribution to the development of biological
LAXATIVES). evolutionary doctrine came from the British
scientist, Charles Darwin, who argued in his
Evacuator book The Origin of Species by Means of Natural
A device for extracting fluid from a cavity. In its Selection (1859) that natural selection resulted
basic form it comprises a hollow flexible bulb in the survival of the fittest organisms. The pre-
attached (using a valve system) to a tube cise biological mechanism of evolution was not
inserted into the cavity. Another valve leads to unravelled until the 20th century, with the dis-
the discharge tube. One use of an evacuator is covery of CHROMOSOMES and GENES and the
to empty the urinary bladder of extraneous development of the science of genetics. Charles
material during surgery for removal of CALCULI Darwins theory was based on his studies of the
or for PROSTATECTOMY. varied and unique animal life in the Galapagos
Islands in the 19th century. He believed that
Evaluation the diversity of life on the planet could be
See PUBLIC HEALTH. ascribed to the combined effects of random
 254 Ewings Sarcoma

variation in living things, inherited by succeed- Excitation

ing generations. When used in neurophysiology, the term means
the triggering of a conducted electrical impulse
Ewings Sarcoma in the membrane of a muscle cell or the nerve
An uncommon but very malignant cancer of fibre controlling it.
the bone in children and young adults, the
condition was first identified as being different Excitement
from OSTEOSARCOMA by Dr J Ewing in 1921. See DELIRIUM; ECSTASY; HYSTERIA; MENTAL
It usually occurs in the limbs or pelvis and soon ILLNESS.
spreads to other parts of the body. Treatment is
E by RADIOTHERAPY and CYTOTOXIC drugs. Since Excoriation
the use of the latter, the number of patients who Excoriation means the destruction of small
survive for five years or more has much pieces of the surface of skin or mucous
improved. membrane.

Ex- (Exo-) Excreta

Prefix meaning outer or outside. Waste material, especially FAECES.

Exanthem Excretion
Rash caused by a systemic infection. Several The process by which the residue of undigested
childhood infections for example, MEASLES food in the gastrointestinal tract (faeces) and
and RUBELLA have characteristic exanthemata. the waste products of the bodys metabolism
mainly as urine via the kidneys, but also as
Exchange Transfusion sweat from the skin, and water and carbon
A method of treating newborn infants with dioxide from the lungs are eliminated.
HAEMOLYTIC DISEASE. Blood is taken out of the
baby through the umbilical vein and is replaced Exercise
with the same quantity of blood from a donor An activity requiring physical exertion. Every-
that is compatible with the mothers blood. The one should take regular exercise: this keeps
procedure is repeated several times to get rid of muscles in tone, maintains the CARDIO-
damaged cells while maintaining the infants VASCULAR SYSTEM in good shape, helps to keep
blood volume and keeping its red cell count weight at an optimum level and promotes
constant. (See also TRANSFUSION.) relaxation and sleep. When an individual is at
rest, the hearts output is 5 litres of blood per
Excimer Laser minute. When running at 12 km (7 miles)
A type of laser that is used to remove thin sheets per hour, this rises to around 25 litres, obliging
of tissue from the surface of the cornea (see EYE), the heart and lungs to operate more efficiently
thus changing the curvature of the eyes corneal and speeding up the metabolism of food to
surface. The procedure is used to excise diseased provide the necessary energy. Lack of exercise
tissue or to correct myopia (see REFRACTION), by children may lead to faulty posture and
when it is known as photorefractive keratec- flabby muscles; in adults it results in an
tomy or lasik. increase in weight and poorly functioning
respiratory and cardiovascular system, with an
Excipient increased chance of heart disease later in life.
An inert substance added to a prescription in Adolescents and adults, participating regularly
order to make the remedy as prescribed more in sporting activities, should train regularly,
suitable in bulk, consistence, or form for preferably under expert supervision, to ensure
administration. that they do not place potentially damaging
demands on their cardiovascular, respiratory
Excision and musculoskeletal systems. Those wanting to
A term applied to the removal of any structure participate in demanding sports would be wise
from the body, when such removal necessitates to have a medical examination before embark-
a certain amount of separation from surround- ing on training programmes (see SPORTS
ing parts: for example, the excision of a tumour, MEDICINE).
of a gland or of a joint. When an opening is
simply made into the body, the term incision is Exfoliation
used; when a limb, or part of one, is removed, The separation, in layers, of pieces of dead bone
the term AMPUTATION is employed. or skin.
 Expectoration 255

Exhalation of hyperthyroidism even when their onset is

Also called expiration, this is the act of breath- simultaneous. Some of the worst examples of
ing air from the lungs out through the bronchi, endocrine exophthalmos occur in the euthyroid
trachea, mouth and nose. (See also RESPIRATION.) state and may appear in patients who have
never had thyrotoxicosis; this disorder is named
Exhibitionism ophthalmic Graves disease. The exophthalmos
Public flaunting of a persons characteristics. of Graves disease is due to autoimmunity (see
Also a term describing the public exposure of IMMUNITY). Antibodies to surface antigens on
genitals to another person, regarded as a form of the eye muscles are produced and this causes an
sexual deviation, colloquially called flashing. inflammatory reaction in the muscle and retro-
orbital tissues. E
Exocrine Gland Exophthalmos may also occur as a result of
A gland that secretes its products through a OEDEMA, injury, cavernous venous THROM-
duct to the surface of the body or of an organ. BOSIS or a tumour at the back of the eye, push-
The sweat glands in the skin and the salivary ing the eyeball forwards. In this situation it is
glands in the mouth are examples. The secre- always unilateral.
tion is set off by a hormone (see HORMONES) or
a NEUROTRANSMITTER. Exopththalmic Goitre
Sometimes called Graves disease, this is a dis-
Exogenous order in which there is overactivity of the thy-
Arising outside the body. For example, exogen- roid gland, protrusion of the eyes, and other
ous DEPRESSION is an illness caused by an out- symptoms. (See HYPERTHYROIDISM.)
side factor such as the death of a close relative;
an exogenous illness may occur because of Exostosis
something eaten in the diet. An outgrowth from a bone: it may be due to
chronic inflammation, constant pressure or ten-
Exomphalos sion on the bone, or tumour-formation. (See
The term applied to a congenital HERNIA BONE, DISORDERS OF.)
formed by the projection of abdominal organs
through the UMBILICUS. Exotoxin
A powerful poison produced by a bacterial cell
Exophthalmometer and secreted into its surrounding environment.
Also known as a proptometer. An instrument Exotoxins are often damaging to only few
used to measure the extent of protrusion of the tissues and they are usually inactivated by
eyeball a development that occurs in certain chemicals, heat and light. Bacteria causing
disorders such as GOITRE, TUMOUR, OEDEMA, BOTULISM, DIPHTHERIA and TETANUS all
injuries, orbital inflammation or cavernous produce exotoxins. (See ENDOTOXIN.)
venous thrombosis (a blood clot in the cavern-
ous sinus in the base of the skull behind each Expectant
eye). (See EXOPHTHALMOS.) A form of treatment in which the cure of the
patient is left mainly to nature, while the phys-
Exophthalmos ician simply watches for any unsatisfactory
Exophthalmos, or PROPTOSIS, refers to forward developments or symptoms, and relieves them
displacement of the eyeball and must be dis- if they occur.
tinguished from retraction of the eyelids, which
causes an illusion of exophthalmos. Lid retrac- Expectorants
tion usually results from activation of the auto- Drugs which are claimed to help the removal of
nomic nervous sytem. Exophthalmos is a more secretions from the AIR PASSAGES although
serious disorder caused by inflammatory and there is no convincing evidence that they do
infiltrative changes in the retro-orbital tissues this. A simple expectorant may, however, be a
and is essentially a feature of Graves disease, useful placebo. Most preparations are available
though it has been described in chronic thy- without a doctors prescription and pharma-
roiditis (see THYROID GLAND, DISEASES OF). cists will advise on which might be helpful for
Exophthalmos commonly starts shortly after particular patients with dry or congestive
the development of thyrotoxicosis but may coughs.
occur months or even years after hyperthyroid-
ism has been successfully treated. The degree of Expectoration
exophthalmos is not correlated with the severity Expectoration means either material brought
 256 Expiration

up from the chest by the AIR PASSAGES, or the Extinction

act by which it is brought up. (1) In behavioural psychology, the lessening of a
conditioned reflex that occurs when it is not
Expiration regularly reinforced. An example is in the
(1) Breathing out air from the lungs. treatment of unsatisfactory behaviour such as
(2) The act of dying. violence, when by preventing the individual
from enjoying the rewards of violent acts
Exploration namely, the attention he or she attracts the
A surgical operation to investigate the cause of a conditioned reflex that is part of the cycle of
patients illness. violence is reduced in strength.
E (2) Elimination of life or of a biological species.
Exposure
(1) A term used in BEHAVIOUR THERAPY to Extirpation
describe a method of treating fears and phobias The total removal of a growth, organ or tissue
(see PHOBIA). The subject is confronted by the by surgery.
circumstances that he or she fears, either grad-
ually or suddenly, with the aim of defusing the Extra-
fear or phobia. Extra- is the Latin prefix meaning outside of, or
(2) The term is also a colloquialism for public in addition such as extracapsular, meaning
exposure by a man of his genitals to achieve outside the capsule of a joint, and extrasystole,
sexual gratification. meaning an additional contraction of the heart.

Exsanguinate Extracellular
The removal of blood from the body. This may An adjective that describes an object or event
occur as the result of a serious accident in which outside a cell. An example is extracellular fluid,
the victim bleeds extensively. Rarely, it may the medium surrounding a cell.
happen that bleeding becomes uncontrollable
during an operation. Extracts
Extracts are preparations, usually of a semi-solid
Extension consistency, containing the active parts of vari-
Extension is the process of straightening or ous plants extracted in one of several ways. In
stretching a limb. When used in the natural the case of some extracts, the juice of the fresh
sense, it involves the contraction of the muscles plant is simply pressed out and purified; in the
opposing those used in FLEXION. In cases of case of others the active principles are dissolved
fractured limbs (see BONE, DISORDERS OF out in water, which is then to a great extent
Bone fractures), extension is employed during driven off by evaporation. Other extracts are
the application of splints, in order to reduce the similarly made by the help of alcohol, and in
displacement caused by the fracture, and pre- some cases ether is the solvent.
vent movement of the broken ends of bone. It is
effected by gently and steadily pulling upon the Extradural
part of the limb beyond the fracture. Extension Outside the DURA MATER, the outermost of the
of a more permanent type is used in the after- three membranes that cover the BRAIN and
treatment of some fractures, as well as in dis- SPINAL CORD. The extradural or epidural space
eases of the spine, by placing the patient upon is the space between the vertebral canal and the
an inclined bed and affixing weights to his or dura mater of the spinal cord. (See ANAESTHESIA
her lower limbs, or to his or her head by means Local anaesthetics: epidural.)
of adhesive plaster or of straps.
Extrapyramidal System
Exteriorisation This is a complex part of the nervous system,
In surgery, the procedure to transfer an organ extending from the cortex to the medulla in the
from its normal place in the body to the skin BRAIN, from which emerge descending spinal
surface. It may be temporary or permanent. A pathways which influence voluntary motor
common example is when the intestine is activity throughout the body. Although the
brought to the abdominal surface as a COL- normal functions of the system are poorly
OSTOMY: this may be permanent because of ser- understood, there are characteristic signs of an
ious disease in the lower part of the COLON, or extrapyramidal LESION. These include disturb-
temporary to allow a disorder in the colon to be ance of voluntary movements, notably slowness
treated. and poverty of movement; disturbance of
 Eye 257

muscular tone, which may be increased or in. Tends to act emotionally rather than
decreased; and involuntary movements, such as intellectually.
a tremor, irregular jerking movements, or slow
writhing movements. Exudation
The process in which some of the constituents
Diseases There are several diseases that result of the blood pass slowly through the walls of the
from lesions to the extrapyramidal system, of small vessels in the course of inflammation, and
which the most common is PARKINSONISM. also means the accumulation resulting from this
Others include WILSONS DISEASE, KERN- process. For example, in PLEURISY the solid,
ICTERUS, CHOREA and ATHETOSIS. rough material deposited on the surface of the
lung is an exudation. E
Extrasensory Perception (ESP)
An alleged way of perceiving current events Eye
(clairvoyance), future events (precognition) or The eye is the sensory organ of sight. It is an
the thoughts of other people (telepathy). ESP elaborate photoreceptor detecting information,
has never been scientifically proven and does in the form of light, from the environment and
not involve the use of any known senses. transmitting this information by a series of elec-
trochemical changes to the BRAIN. The visual
cortex is the part of the brain that processes this
Extrasystole information (i.e. the visual cortex is what sees
Extrasystole is a term applied to premature con-
the environment). There are two eyes, each a
traction of one or more of the chambers of the
roughly spherical hollow organ held within a
heart. A beat of the heart occurs sooner than it
bony cavity (the orbit). Each orbit is situated on
should do in the ordinary rhythm and is fol-
the front of the skull, one on each side of the
lowed by a longer rest than usual before the
nose. The eye consists of an outer wall of three
next beat. In an extrasystole, the stimulus to
main layers and a central cavity divided into
contraction arises in a part of the heart other
three.
than the usual. Extrasystoles often give rise to
an unpleasant sensation as of the heart stum-
The outer coat consists of the sclera and
bling over a beat, but their occurrence is not
the cornea; their junction is called the limbus.
usually serious.
SCLERA This is white, opaque, and constitutes
the posterior five-sixths of the outer coat. It is
Extrauterine Pregnancy made of dense fibrous tissue. The sclera is vis-
See ECTOPIC PREGNANCY. ible anteriorly, between the eyelids, as the white
of the eye. Posteriorly and anteriorly it is
Extravasation covered by Tenons capsule, which in turn is
An escape of fluid from the vessels or passages covered by transparent conjunctiva. There is a
which ought to contain it. Extravasation of hole in the sclera through which nerve fibres
blood due to tearing of vessel walls is found in from the retina leave the eye in the optic nerve.
STROKE, and in the commoner condition Other smaller nerve fibres and blood vessels also
known as a bruise. Extravasation of urine takes pass through the sclera at different points.
place when the bladder or the URETHRA is rup- CORNEA This constitutes the transparent, col-
tured by a blow on the abdomen or on the ourless anterior one-sixth of the eye. It is trans-
crutch (PERINEUM), or torn in a fracture of parent in order to allow light into the eye and is
the pelvis. Intravenous infusions frequently more steeply curved than the sclera. Viewed
extravasate. from in front, the cornea is roughly circular.
Most of the focusing power of the eye is pro-
Extrinsic vided by the cornea (the lens acts as the fine
(1) Originating outside the body. adjustment). It has an outer epithelium, a cen-
(2) An extrinsic muscle is one whose origin is tral stroma and an inner endothelium. The
some way from the part of the body it acts upon cornea is supplied with very fine nerve fibres
for example, the muscles controlling the which make it exquisitely sensitive to pain. The
movement of the eyeball which are attached to central cornea has no blood supply it relies
the bony orbit in which the eye sits. mainly on aqueous humour for nutrition.
Blood vessels and large nerve fibres in the cor-
Extrovert nea would prevent light from entering the eye.
A person who is outgoing, enjoys mixing with LIMBUS is the junction between cornea and
others and looks for fresh activities to take part sclera. It contains the trabecular meshwork, a
 258 Eye

sieve-like structure through which aqueous disc thus produces a physiological blind spot in
humour leaves the eye. the visual field.
The retina can be subdivided into several
The middle coat (uveal tract) consists areas:
of the choroid, ciliary body and iris. PERIPHERAL RETINA contains mainly rods and
CHOROID A highly vascular sheet of tissue lin- a few scattered cones. Visual acuity from this
ing the posterior two-thirds of the sclera. The area is fairly coarse.
network of vessels provides the blood supply for MACULA LUTEA So-called because histologi-
the outer half of the retina. The blood supply of cally it looks like a yellow spot. It occupies an
the choroid is derived from numerous ciliary area 45 mm in diameter lateral to the optic
E vessels which pierce the sclera in front and disc. This area of specialised retina can produce
behind. a high level of visual acuity. Cones are abundant
CILIARY BODY A ring of tissue extending 6 mm here but there are few rods.
back from the anterior limitation of the sclera. FOVEA CENTRALIS A small central depression at
The various muscles of the ciliary body by their the centre of the macula. Here the cones are
contractions and relaxations are responsible for tightly packed; rods are absent. It is responsible
changing the shape of the lens during ACCOM- for the highest levels of visual acuity.
MODATION. The ciliary body is lined by cells
that secrete aqueous humour. Posteriorly, the The chambers of the eye There are
ciliary body is continuous with the choroid; three: the anterior and posterior chambers, and
anteriorly it is continuous with the iris. the vitreous cavity.
IRIS A flattened muscular diaphragm that is ANTERIOR CHAMBER Limited in front by the
attached at its periphery to the ciliary body, and inner surface of the cornea, behind by the iris
has a round central opening the pupil. By and pupil. It contains a transparent clear watery
contraction and relaxation of the muscles of the fluid, the aqueous humour. This is constantly
iris, the pupil can be dilated or constricted being produced by cells of the ciliary body and
(dilated in the dark or when aroused; con- constantly drained away through the trabecular
stricted in bright light and for close work). The meshwork. The trabecular meshwork lies in the
iris forms a partial division between the anterior angle between the iris and inner surface of the
chamber and the posterior chamber of the eye. cornea.
It lies in front of the lens and forms the back POSTERIOR CHAMBER A narrow space between
wall of the anterior chamber. The iris is visible the iris and pupil in front and the lens behind.
from in front, through the transparent cornea, It too contains aqueous humour in transit from
as the coloured part of the eye. The amount the ciliary epithelium to the anterior chamber,
and distribution of iris pigment determine the via the pupil.
colour of the iris. The pupil is merely a hole in VITREOUS CAVITY The largest cavity of the eye.
the centre of the iris and appears black. In front it is bounded by the lens and behind by
the retina. It contains vitreous humour.
The inner layer The retina is a multi-
layered tissue (ten layers in all) which extends Lens Transparent, elastic and biconvex in
from the edges of the optic nerve to line the cross-section, it lies behind the iris and in front
inner surface of the choroid up to the junction of the vitreous cavity. Viewed from the front it
of ciliary body and choroid. Here the true ret- is roughly circular and about 10 mm in diam-
ina ends at the ora serrata. The retina contains eter. The diameter and thickness of the lens
light-sensitive cells of two types: (i) cones cells vary with its accommodative state. The lens
that operate at high and medium levels of consists of:
illumination; they subserve fine discrimination CAPSULE A thin transparent membrane sur-
of vision and colour vision; (ii) rods cells that rounding the cortex and nucleus.
function best at low light intensity and subserve CORTEX This comprises newly made lens fibres
black-and-white vision. that are relatively soft. It separates the capsule
The retina contains about 6 million cones on the outside from the nucleus at the centre of
and about 100 million rods. Information from the lens.
them is conveyed by the nerve fibres which are NUCLEUS The dense central area of old lens
in the inner part of the retina, and leave the eye fibres that have become compacted by new lens
in the optic nerve. There are no photoreceptors fibres laid down over them.
at the optic disc (the point where the optic ZONULE Numerous radially arranged fibres
nerve leaves the eye) and therefore there is no attached between the ciliary body and the lens
light perception from this small area. The optic around its circumference. Tension in these
 Eye 259

zonular fibres can be adjusted by the muscles of of connective tissue that forms a hammock on
the ciliary body, thus changing the shape of the which the eye rests and which is slung between
lens and altering its power of accommodation. the medial and lateral walls of the orbit. Finally,
VITREOUS HUMOUR A transparent jelly-like the orbital septum, a sheet of connective tissue
structure made up of a network of collagen extending from the anterior margin of the orbit
fibres suspended in a viscid fluid. Its shape con- into the lids, helps keep the eye in place. A pad
forms to that of the vitreous cavity within of fat fills in the orbit behind the eye and acts as
which it is contained: that is, it is spherical a cushion for the eye.
except for a shallow concave depression on its
anterior surface. The lens lies in this depression. Conjunctiva A transparent mucous mem-
brane that extends from the limbus over the E
Eyelids These are multilayered curtains of anterior sclera or white of the eye. This is the
tissue whose functions include spreading of the bulbar conjunctiva. The conjunctiva does not
tear film over the front of the eye to prevent cover the cornea. Conjunctiva passes from the
desiccation; protection from injury or external eye on to the inner surface of the eyelid at the
irritation; and to some extent the control of fornices and is continuous with the tarsal con-
light entering the eye. Each eye has an upper junctiva. The semilunar fold is the vertical cres-
and lower lid which form an elliptical opening cent of conjunctiva at the medial aspect of the
(the palpebral fissure) when the eyes are open. palpebral fissure. The caruncle is a piece of
The lids meet at the medial canthus and lateral modified skin just within the inner canthus.
canthus respectively. The inner medial canthus
is fixed; the lateral canthus more mobile. An Eye muscles The extra-ocular muscles.
epicanthus is a fold of skin which covers the There are six in all, the four rectus muscles
medial canthus in oriental races. (superior, inferior, medial and lateral rectus
Each lid consists of several layers. From front muscles) and two oblique muscles (superior and
to back they are: very thin skin; a sheet of inferior oblique muscles). The muscles are
muscle (orbicularis oculi, whose fibres are con- attached at various points between the bony
centric around the palpebral fissure and which orbit and the eyeball. By their combined action
produce closure of the eyelids); the orbital sep- they move the eye in horizontal and vertical
tum (modified near the lid margin to form the gaze. They also produce torsional movement of
tarsal plates); and finally, lining the back surface the eye (i.e. clockwise or anticlockwise move-
of the lid, the conjunctiva (known here as tarsal ments when viewed from the front).
conjunctiva). At the free margin of each lid are
the eyelashes, the openings of tear glands which Lacrimal apparatus There are two com-
lie within the lid, and the lacrimal punctum. ponents: a tear-production system, namely the
Toward the medial edge of each lid is an eleva- lacrimal gland and accessory lacrimal glands;
tion known as the papilla: the lacrimal punc- and a drainage system.
tum opens into this papilla. The punctum Tears keep the front of the eye moist; they
forms the open end of the cannaliculus, part of also contain nutrients and various components
the tear-drainage mechanism. to protect the eye from infection. Crying results
from excess tear production. The drainage sys-
Orbit The bony cavity within which the eye is tem cannot cope with the excess and therefore
held. The orbits lie one on either side of the tears overflow on to the face. Newborn babies
nose, on the front of the skull. They afford con- do not produce tears for the first three months
siderable protection for the eye. Each is roughly of life.
pyramidal in shape, with the apex pointing LACRIMAL GLAND Located below a small
backwards and the base forming the open depression in the bony roof of the orbit.
anterior part of the orbit. The bone of the Numerous tear ducts open from it into pre-
anterior orbital margin is thickened to protect dominantly the upper lid. Accessory lacrimal
the eye from injury. There are various openings glands are found in the conjunctiva and within
into the posterior part of the orbit namely the the eyelids: the former open directly on to the
optic canal, which allows the optic nerve to surface of the conjunctiva; the latter on to the
leave the orbit en route for the brain, and the eyelid margin.
superior orbital and inferior orbital fissures, LACRIMAL DRAINAGE SYSTEM This consists of:
which allow passage of nerves and blood vessels PUNCTUM An elevated opening toward the
to and from the orbit. The most important medial aspect of each lid. Each punctum opens
structures holding the eye within the orbit are into a canaliculus.
the extra-ocular muscles, a suspensory ligament CANALICULUS A fine tube-like structure run-
 260 Eyeball

ning within the lid, parallel to the lid margin. Cataract A term used to describe any opacity
The canaliculi from upper and lower lid join to in the lens of the eye, from the smallest spot to
form a common canaliculus which opens into total opaqueness. The prevalence of cataracts is
the lacrimal sac. age-related: 65 per cent of individuals in their
LACRIMAL SAC A small sac on the side of the sixth decade have some degree of lens opacity,
nose which opens into the nasolacrimal duct. while all those over 80 are affected. Cataracts
During blinking, the sac sucks tears into itself are the most important cause of blindness
from the canaliculus. Tears then drain by grav- worldwide. Symptoms will depend on whether
ity down the nasolacrimal duct. one or both eyes are affected, as well as the
NASOLACRIMAL DUCT A tubular structure position and density of the cataract(s). If only
E which runs down through the wall of the nose one eye is developing a cataract, it may be some
and opens into the nasal cavity. time before the person notices it, though read-
ing may be affected. Some people with cataracts
Visual pathway Light stimulates the rods become shortsighted, which in older people
and cones of the retina. Electrochemical mes- may paradoxically improve their ability to
sages are then passed to nerve fibres in the retina read. Bright light may worsen vision in those
and then via the optic nerve to the optic chi- with cataracts.
asm. Here information from the temporal The extent of visual impairment depends on
(outer) half of each retina continues to the same the nature of the cataracts, and the first symp-
side of the brain. Information from the nasal toms noticed by patients include difficulty in
(inner) half of each retina crosses to the other recognising faces and in reading, while prob-
side within the optic chiasm. The rearranged lems watching television or driving, especially
nerve fibres then pass through the optic tract to at night, are pointers to the condition. Catar-
the lateral geniculate body, then the optic radi- acts are common but are not the only cause of
ation to reach the visual cortex in the occipital deteriorating vision. Patients with cataracts
lobe of the brain. should be able to point to the position of a light
and their pupillary reactions should be normal.
Eyeball If a bright light is shone on the eye, the lens
See EYE. may appear brown or, in advanced cataracts,
white (see diagram).
Eye, Disorders of While increasing age is the commonest cause
of cataract in the UK, patients with DIABETES
Arcus senilis The white ring or crescent MELLITUS, UVEITIS and a history of injury to
which tends to form at the edge of the cornea the eye can also develop the disorder. Prolonged
with age. It is uncommon in the young, when it STEROID treatment can result in cataracts.
may be associated with high levels of blood Children may develop cataracts, and in them
lipids (see LIPID). the condition is much more serious as vision
may be irreversibly impaired because develop-
Astigmatism (See ASTIGMATISM.) ment of the brains ability to interpret visual
signals is hindered. This may happen even if the
Blepharitis A chronic inflammation of the cataracts are removed, so early referral for
lid margins. SEBORRHOEA and staphylococcal treatment is essential. One of the physical signs
infection are likely contributors. The eyes are which doctors look for when they suspect catar-
typically intermittently red, sore and gritty over act in adults as well as in children is the red
months or years. Treatment is difficult and may reflex. This is observable when an ophthalmo-
fail. Measures to reduce debris on the lid mar- scopic examination of the eye is made (see OPH-
gins, intermittent courses of topical antibiotics, THALMOSCOPE). Identification of this red reflex
steroids or systemic antibiotics may help the (a reflection of light from the red surface of the
sufferer. retina see EYE) is a key diagnostic sign in
children, especially young ones.
Blepharospasm Involuntary closure of the There is no effective medical treatment for
eye. This may accompany irritation but may established cataracts. Surgery is necessary and
also occur without an apparent cause. It may be the decision when to operate depends mainly
severe enough to interfere with vision. Treat- on how the cataract(s) affect(s) the patients
ment involves removing the source of irritation, vision. Nowadays, surgery can be done at any
if present. Severe and persistent cases may time with limited risk. Most patients with a
respond to injection of Botulinum toxin into vision of 6/18 6/10 is the minimum standard
the orbicularis muscle. for driving or worse in both eyes should
 Eye, Disorders of 261

Cataract: the opaque lens of any eye with cataract (left) is replaced with an implanted artificial lens (right).

benefit from surgery, though elderly people may keratitis (see below) for example, adenovirus
tolerate visual acuity of 6/18 or worse, so sur- infection, herpetic infection.
gery must be tailored to the individuals needs. The cause can be infective (bacteria, viruses
Younger people with a cataract will have more or CHLAMYDIA), chemical (e.g. acids, alkalis) or
demanding visual requirements and so may opt allergic (e.g. in hay fever). Conjunctivitis may
for an earlier operation. Most cataract surgery also be caused by contact lenses, and preserva-
in Britain is now done under local anaesthetic tives or even the drugs in eye drops may cause
and uses the phaco-emulsification method. A conjunctival inflammation. Conjunctivitis may
small hole is made in the anterior capsule of the addtionally occur in association with other ill-
lens after which the hard lens nucleus is liqui- nesses for example, upper-respiratory-tract
fied ultrasonically. A replacement lens is infection, Stevens-Johnson syndrome (see ERY-
inserted into the empty lens bag (see diagram). THEMA erythema multiforme) or REITERS
Patients usually return to their normal activities SYNDROME. The treatment depends on the
within a few days of the operation. A recent cause. In many patients acute conjunctivitis is
development under test in the USA for children self-limiting.
requiring cataract operations is an intra-ocular
flexible implant whose magnifying power can Dacryocystitis Inflammation of the lac-
be altered as a child develops, thus precluding rimal sac. This may present acutely as a red,
the need for a series of corrective operations as painful swelling between the nose and the lower
happens now. lid. An abscess may form which points through
the skin and which may need to be drained by
Chalazion A firm lump in the eyelid relating incision. Systemic antibiotics may be necessary.
to a blocked meibomian gland, felt deep within Chronic dacryocystitis may occur with recur-
the lid. Treatment is not always necessary; a rent discharge from the openings of the tear
proportion spontaneously resolve. There can be ducts and recurrent swelling of the lacrimal sac.
associated infection when the lid becomes red Obstruction of the tear duct is accompanied by
and painful requiring antibiotic treatment. If watering of the eye. If the symptoms are
troublesome, the chalazion can be incised under troublesome, the patients tear passageways
local anaesthetic. need to be surgically reconstructed.

Conjunctivitis Inflammation of the con- Ectropion The lid margin is everted usu-
junctiva (see EYE) which may affect one or both ally the lower lid. Ectropion is most commonly
eyes. Typically the eye is red, itchy, sticky and associated with ageing, when the tissues of the
gritty but is not usually painful. Redness is not lid become lax. It can also be caused by shorten-
always present. Conjunctivitis can occasionally ing of the skin of the lids such as happens with
be painful, particularly if there is an associated scarring or mechanical factors for example,
 262 Eye, Disorders of

a tumour pulling the skin of the lower lid others are focused on or behind the retina.
downwards. Ectropion tends to cause watering Astigmatism can accompany hypermetropia or
and an unsightly appearance. The treatment is myopia. It may be corrected by cylindrical
surgical. lenses: these consist of a slice from the side of a
cylinder (i.e. curved in one meridian and flat in
Entropion The lid margin is inverted usu- the meridian at right-angles to it).
ally the lower lid. Entropion is most commonly
associated with ageing, when the tissues of the Keratitis Inflammation of the cornea in
lid become lax. It can also be caused by shorten- response to a variety of insults viral, bacterial,
ing of the inner surfaces of the lids due to scar- chemical, radiation, or mechanical trauma.
E ring for example, TRACHOMA or chemical Keratitis may be superficial or involve the
burns. The inwardly directed lashes cause irrita- deeper layers, the latter being generally more
tion and can abrade the cornea. The treatment serious. The eye is usually red, painful and
is surgical. photophobic. Treatment is directed at the
cause.
Episcleritis Inflammation of the EPISCLERA.
There is usually no apparent cause. The Nystagmus Involuntary rhythmic oscilla-
inflammation may be diffuse or localised and tion of one or both eyes. There are several
may affect one or both eyes. It sometimes causes including nervous disorders, vestibular
recurs. The affected area is usually red and disorders, eye disorders and certain drugs
moderately painful. Episcleritis is generally not including alcohol.
thought to be as painful as scleritis and does not
Ophthalmia Inflammation of the eye, espe-
lead to the same complications. Treatment is
cially the conjunctiva (see conjunctivitis, above).
generally directed at improving the patients
Ophthalmia neonatorum is a type of con-
symptoms. The inflammation may respond to
junctivitis that occurs in newborn babies. They
NON-STEROIDAL ANTI-INFLAMMATORY DRUGS
catch the disease when passing through an
(NSAIDS) or topical CORTICOSTEROIDS.
infected birth canal during their mothers
labour (see PREGNANCY AND LABOUR). CHLA-
Errors of refraction (Ametropia.) These
MYDIA and GONORRHOEA are the two most
will occur when the focusing power of the lens
common infections. Treatment is effective with
and cornea does not match the length of the
antibiotics: untreated, the infection may cause
eye, so that rays of light parallel to the visual
permanent eye damage.
axis are not focused at the fovea centralis (see
EYE). There are three types of refractive error: Pinguecula A benign degenerative change in
HYPERMETROPIA or long-sightedness. The the connective tissue at the nasal or temporal
refractive power of the eye is too weak, or the limbus (see EYE). This is visible as a small, flat-
eye is too short so that rays of light are brought tened, yellow-white lump adjacent to the
to a focus at a point behind the retina. Long- cornea.
sighted people can see well in the distance but
generally require glasses with convex lenses for Pterygium Overgrowth of the conjunctival
reading. Uncorrected long sight can lead to tissues at the limbus on to the cornea (see EYE).
headaches and intermittent blurring of vision This usually occurs on the nasal side and is
following prolonged close work (i.e. eye strain). associated with exposure to sunlight. The
As a result of ageing, the eye becomes gradually pterygium is surgically removed for cosmetic
long-sighted, resulting in many people needing reasons or if it is thought to be advancing
reading glasses in later life: this normal process towards the visual axis.
is known as presbyopia. A particular form of
long-sightedness occurs after cataract extraction Ptosis Drooping of the upper lid. May occur
(see above). because of a defect in the muscles which raise
MYOPIA(Short sight or near sight.) Rays of the lid (levator complex), sometimes the result
light are brought to a focus in front of the retina of ageing or trauma. Other causes include
because the refractive power of the eye is too HORNERS SYNDROME, third cranial nerve
great or the eye is too short. Short-sighted PALSY, MYASTHENIA GRAVIS, and DYSTROPHIA
people can see close to but need spectacles with MYOTONICA. The cause needs to be determined
concave lenses in order to see in the distance. and treated if possible. The treatment for a
ASTIGMATISMThe refractive power of the eye is severely drooping lid is surgical, but other
not the same in each meridian. Some rays of measures can be used to prop up the lid with
light may be focused in front of the retina while varying success.
 Eye, Disorders of 263

Retina, disorders of The retina can be as doors and chairs, and are therefore able to get
damaged by disease that affects the retina alone, around and about reasonably well. There is no
or by diseases affecting the whole body. effective treatment in the majority of cases.
Retinopathy is a term used to denote an RETINITIS PIGMENTOSAA group of rare,
abnormality of the retina without specifying a inherited diseases characterised by the devel-
cause. Some retinal disorders are discussed opment of night blindness and tunnel vision.
below. Symptoms start in childhood and are progres-
DIABETIC RETINOPATHY Retinal disease occur- sive. Many patients retain good visual acuity,
ring in patients with DIABETES MELLITUS. It is although their peripheral vision is limited. One
the commonest cause of blind registration in of the characteristic findings on examination is
Great Britain of people between the ages of 20 collections of pigment in the retina which have E
and 65. Diabetic retinopathy can be divided a characteristic shape and are therefore known
into several types. The two main causes of as bone spicules. There is no effective
blindness are those that follow: first, develop- treatment.
ment of new blood vessels from the retina, with RETINAL DETACHMENTusually occurs due to
resultant complications and, second, those fol- the development of a hole in the retina. Holes
lowing water logging (oedema) of the macula. can occur as a result of degeneration of the ret-
Treatment is by maintaining rigid control of ina, traction on the retina by the vitreous, or
blood-sugar levels combined with laser treat- injury. Fluid from the vitreous passes through
ment for certain forms of the disease in par- the hole causing a split within the retina; the
ticular to get rid of new blood vessels. inner part of the retina becomes detached from
HYPERTENSIVE RETINOPATHY Retinal disease the outer part, the latter remaining in contact
secondary to the development of high blood with the choroid. Detached retina loses its abil-
pressure. Treatment involves control of the ity to detect light, with consequent impairment
blood pressure (see HYPERTENSION). of vision. Retinal detachments are more com-
SICKLE CELL RETINOPATHY People with sickle mon in the short-sighted, in the elderly or fol-
cell disease (see under ANAEYIA) can develop a lowing cataract extraction. Symptoms include
number of retinal problems including new spots before the eyes (floaters), flashing lights
blood vessels from the retina. and a shadow over the eye with progressive loss
RETINOPATHY OF PREMATURITY (ROP) Previ- of vision. Treatment by laser is very effective if
ously called retrolental fibroplasia (RLF), this is caught early, at the stage when a hole has
a disorder affecting low-birth-weight premature developed in the retina but before the retina has
babies exposed to oxygen. Essentially, new become detached. The edges of the hole can be
blood vessels develop which cause extensive spot welded to the underlying choroid. Once a
traction on the retina with resultant retinal detachment has occurred, laser therapy cannot
detachment and poor vision. be used; the retina has to be repositioned. This
RETINAL ARTERY OCCLUSION; RETINAL VEIN is usually done by indenting the wall of the eye
OCCLUSION These result in damage to those from the outside to meet the retina, then mak-
areas of retina supplied by the affected blood ing the retina stick to the wall of the eye by
vessel: the blood vessels become blocked. If the inducing inflammation in the wall (by freezing
peripheral retina is damaged the patient may be it). The outcome of surgery depends largely on
completely symptom-free, although areas of the extent of the detachment and its duration.
blindness may be detected on examination of Complicated forms of detachment can occur
field of vision. If the macula is involved, visual due to diabetic eye disease, injury or tumour.
loss may be sudden, profound and permanent. Each requires a specialised form of treatment.
There is no effective treatment once visual loss
has occurred. Scleritis Inflammation of the sclera (see EYE).
SENILE MACULAR DEGENERATION (Senile This can be localised or diffuse, can affect the
indicates age of onset and has no bearing on anterior or the posterior sclera, and can affect
mental state.) This is the leading cause of one or both eyes. The affected eye is usually red
blindness in the elderly in the western world. and painful. Scleritis can lead to thinning and
The average age of onset is 65 years. Patients even perforation of the sclera, sometimes with
initially notice a disturbance of their vision little sign of inflammation. Posterior scleritis in
which gradually progresses over months or particular may cause impaired vision and
years. They lose the ability to recognise fine require emergency treatment. There is often no
detail; for example, they cannot read fine print, apparent cause, but there are some associated
sew, or recognise peoples faces. They always conditions for example, RHEUMATOID ARTH-
retain the ability to recognise large objects such RITIS, GOUT, and an autoimmune disease
264 Eye Drops

affecting the nasal passages and lungs called Blunt injuries These may cause haemor-
Wegeners granulomatosis. Treatment depends rhage inside the eye, cataract, retinal detach-
on severity but may involve NON-STEROIDAL ment or even rupture of the eye (see also EYE,
ANTI-INFLAMMATORY DRUGS (NSAIDS), topical DISORDERS OF). Injuries from large blunt
CORTICOSTEROIDS or systemic immunosup- objects for example, a squash ball may also
pressive drugs. cause a blow-out fracture of the orbital floor
resulting in double vision. Surgical treatment
Stye Infection of a lash follicle. This presents may be required depending on the patients
as a painful small red lump at the lid margin. specific problems.
It often resolves spontaneously but may
require antibiotic treatment if it persists or Chemical burns Most chemical splashes
recurs. cause conjunctivitis and superficial keratitis in
the victim (see EYE, DISORDERS OF); both condi-
Sub-conjunctival haemorrhage Hae- tions are self-limiting. Alkalis are, however,
morrhage between the conjunctiva and the more likely to penetrate deeper into the eye and
underlying episclera. It is painless. There is usu- cause permanent damage, particularly to the
ally no apparent cause and it resolves cornea. Prompt irrigation is important. Further
spontaneously. treatment may involve testing the pH of the
tears, topical antibiotics and CORTICO-
STEROIDS, and vitamin C (drops or tablets see
Trichiasis Inward misdirection of the lashes. APPENDIX 5: VITAMINS), depending on the
Trichiasis occurs due to inflammation of or nature of the injury.
trauma to the lid margin. Treatment involves
removal of the patients lashes. Regrowth may Corneal abrasion Loss of corneal epi-
be prevented by electrolysis, by CRYOTHERAPY thelium (outermost layer). Almost any sort of
to the lid margin, or by surgery. injury to the eye may cause this. The affected
For the subject of artificial eyes, see under eye is usually very painful. In the absence of other
PROSTHESIS; also GLAUCOMA, SQUINT and
problems, the epithelium heals rapidly: small
UVEITIS.
defects may close within 24 hours. Treatment
conventionally consists of antibiotic ointment
Eye Drops and sometimes a pad over the injured eye.
Eye drops and ointment are used extensively in
the treatment of eye disease. They should be Foreign bodies Most foreign bodies
used as instructed by the prescribing physician. which hit the eye are small and are found in
Most can be used for one month after the bottle the conjunctival sac or on the cornea; most
has been opened but should then be discarded are superficial and can be easily removed. A
and a repeat prescription obtained if necessary. few foreign bodies penetrate deeper and may
Any eye drops or ointment can have side- cause infection, cataract, retinal detachment
effects, and any difficulty with them should be or haemorrhage within the eye. The foreign
referred to the prescribing physician. body is usually removed and the damage
repaired; nevertheless the victims sight may
Eye Injuries have been permanently damaged. Particularly
Victims of eye injuries are advised to seek dangerous activities include hammering or
prompt medical advice if the injury is at all chiselling on metal or stone; people carrying
serious or does not resolve with simple first-aid out these activities (and others, such as hedge-
measures for example, by washing out a for- cutting and grass-strimming) should wear
eign body using an eye bath. protective goggles.
 bowel habit, persistent diarrhoea or a change

F from the normal dark brown (caused by the bile

pigment, stercobilin) to very pale or very dark
stools are reasons for seeking medical advice.
Blood in the stools may be due to HAEMOR-
RHOIDS or something more serious, and anyone
with such symptoms should see a doctor.
Fabricated and Induced Illness
See MUNCHAUSENS SYNDROME. Incontinence of the bowels, or inability to
retain the stools, is found in certain diseases in
Face Lift which the sphincter muscles those muscles
An operation to reduce wrinkles and lift loose that naturally keep the bowel closed relax. It is
skin on the face of mature persons with the aim also a symptom of disease in, or injury to, the
of making them look younger. It can be per- SPINAL CORD.
formed under local anaesthetic as an outpatient
or with general anaesthesia as an inpatient. The Pain on defaecation is a characteristic symp-
operation is regarded as cosmetic and is usually tom of a FISSURE at the ANUS or of inflamed
done in the private health-care sector in the haemorrhoids, and is usually sharp. Pain of a
UK. duller character associated with the movements
of the bowels may be caused by inflammation
Facial Nerve in the other pelvic organs.
The seventh cranial nerve (arising from the CONSTIPATION and DIARRHOEA are con-
BRAIN), supplying the muscles of expression in sidered under separate headings.
the face, being purely a motor nerve. It enters
the face immediately below the ear after split- Fainting
ting up into several branches. (See BELLS PALSY.) Fainting, or SYNCOPE, is a temporary loss of
consciousness caused by inadequate supply of
Facies blood to the brain. It may be preceded by nau-
Facies is a term applied to the expression or sea, sweating, loss of vision, and ringing in the
appearance of the face. ears (see TINNITUS). It is most often caused by
pooling of blood in the extremities, which
Factitious Urticaria reduces venous return (see CIRCULATORY SYS-
See DERMOGRAPHISM. TEM OF THE BLOOD) and thus cardiac output:
this may be due to hot weather or prolonged
Factor VIII standing. Occasionally, fainting on standing
A coagulative blood protein that is a constituent occurs in people with low blood pressure (see
of the COAGULATION cascade an essential HYPOTENSION), autonomic neuropathy (in
component in the clotting of blood. Those which normal vasomotor reflexes are absent), or
people with the inherited disorder, HAEMO- those taking antihypertensive drugs. A pro-
PHILIA, have abnormally low amounts of factor longed rise in intrathoracic pressure caused by
VIII and so bleed more when cut. They are coughing, MICTURITION, or VALSALVAS MAN-
treated with a concentrated version to reduce OEUVRE also impedes venous return and may
the tendency to bleed. cause fainting. HYPOVOLAEMIA produced by
bleeding, prolonged diarrhoea, or vomiting
Faeces may also cause fainting, and the condition can
Faeces, or stools, consist of the remainder of the be produced by severe pain or emotional upset.
food after it has passed through the alimentary Cardiac causes, such as severe stenotic valve
canal and been subjected to the action of the disease or rhythm disturbances (particularly
digestive juices, and after the nutritious parts complete heart block or very rapid tachycar-
have been absorbed by the intestinal mucous dias), may result in fainting (see HEART, DIS-
membrane. The stools also contain various EASES OF). Treatment must be directed towards
other matters, such as pigment derived from the the underlying cause, but immediate first aid
BILE, and large quantities of bacteria which are consists of laying the patient down and elevat-
the main component of human stools. The ing the legs.
stools are passed once daily by most people, but
infants have several evacuations of the bowels in Faith Healing
24 hours and some adults may defaecate only The facility, claimed by some people, to cure
two or three times weekly. Sudden changes in disease by a healing force present in their
 266 Fallen Arches

make-up. The healer transmits the force by Farmers Lung

direct contact with the person seeking treat- A form of external allergic ALVEOLITIS caused
ment. Strong religious beliefs are usually the by the inhalation of dust from mouldy hay or
characteristics of the healer and his or her sub- straw.
ject. The force is inexplicable to science but
some medically qualified doctors have been Fascia
convinced of its beneficial effect in certain Sheets or bands of fibrous tissue which enclose
individuals. the body tissues beneath the skin and connect
the muscles.
Fallen Arches
Weakness in the muscles that support the bony Fasciitis
arches of the foot. The result is flat feet, a con- Inflammation of FASCIA. The most common
F dition that can adversely affect a persons ability site is the sole of the foot, where it is known as
to walk and run normally. plantar fasciitis. It is characterised by gnawing
pain. There is no specific treatment, but the
Falling Sickness condition usually clears up spontaneously
An old name for EPILEPSY. though over a considerable time.
Fallopian Tubes Fascioliasis
Tubes, one on each side, lying in the pelvic area Disease caused by the liver fluke, Fasciola hepat-
of the abdomen, which are attached at one end ica. This is found in sheep, cattle and other
to the UTERUS, and have the other unattached herbivorous animals, in which it is the cause of
but lying close to the ovary (see OVARIES). Each the condition known as liver rot. It measures
is 10125 cm (45 inches) long, large at the about 35 13 mm, and is transmitted to
end next to the ovary, but communicating with humans from the infected animals by snails. In
the womb by an opening which admits only a Britain it is the most common disease found in
bristle. These tubes conduct the ova (see OVUM) animal slaughterhouses. The danger to humans
from the ovaries to the interior of the womb. is in eating vegetables particularly wild water-
Blockage of the Fallopian tubes by a chronic cress that have been infected by snails; there
inflammatory process resulting from infection have been several outbreaks of fascioliasis in
is a not uncommon cause of infertility in Britain due to eating contaminated wild water-
women. (See ECTOPIC PREGNANCY; REPRO- cress, and much larger outbreaks from the same
DUCTIVE SYSTEM.)
cause have been reported in France. The disease
is characterised by fever, dyspepsia (indiges-
Fallots Tetralogy tion), heavy sweating, loss of appetite, abdom-
See TETRALOGY OF FALLOT.
inal pain, URTICARIA, and a troublesome cough.
False-Memory Syndrome In the more serious cases there may be severe
See REPRESSED MEMORY THERAPY. damage to the LIVER, with or without JAUN-
DICE. The diagnosis is clinched by the finding
Familial of the eggs of the fluke in the stools. The two
A description of a disorder, illness or character- drugs used in treatment are bithionol and
istic that runs in families. chloroquine. Even though many cases are quite
mild and recover spontaneously, prevention is
Famotidine particularly important. This consists primarily
One of the H2 RECEPTOR ANTAGONISTS used to of never eating wild watercress, as this is the
heal gastric ulcers (see STOMACH, DISEASES OF) main cause of infestation. Lettuces have also
and DUODENAL ULCER. The drug works by been found to be infested.
blocking H2 receptors and so cutting the output
of gastric acid. It is taken orally; side-effects Fasciotomy
may include dizziness, changed bowel habit, An operation to relieve pressure on muscles
fatigue, rashes, confusion, reversible liver dam- caused by tight surrounding FASCIA or fibrous
age and headache. CONNECTIVE TISSUE. The fascia is slit with an
incision.
Fansidar
A combination of PYRIMETHAMINE and sulf- Fasting
adoxine used in conjunction with other anti- Fasting is the abstention from, or deprivation
malarial drugs to treat falciparum malaria (see of, food and drink. It may result from a genuine
MALARIA). desire to lose weight in an attempt to improve
 Fat Necrosis 267

ones health and/or appearance or from a women is below 20 per cent and 25 per cent
MENTAL ILLNESS such as DEPRESSION, or from respectively of their body weight. In economic-
one of the EATING DISORDERS. Certain religious ally developed countries, middle-aged men and
customs and practices may demand periods of women usually undergo a steady increase in
fasting. Forced fasting, often extended, has been body fat. This is probably not a feature of age-
used for many years as an effective means of ing, however, since in developing nations,
torture. which have different diets and greater levels of
Without food and drink the body rapidly physical activity, increased age does not bring
becomes thinner and lighter as it draws upon its with it an increase in body fat. One widely used
stored energy reserves, initially mainly fat. Body means to estimate whether a person has excess
temperature gradually falls, and muscle is pro- fat is to measure his or her skinfold thickness
gressively broken down as the body struggles to on the arms and torso. The distribution of fat
maintain its vital functions. Dehydration, lead- can be a pointer to certain disorders: those F
ing to cardiovascular collapse, inevitably follows adults, for example, who deposit their fat
unless a basic amount of water is taken par- abdominally rather than on their hips an
ticularly if the bodys fluid output is high, such android rather than a gynaecoid distribution
as may occur with excessive sweating. are particularly susceptible to disease of the
After prolonged fasting the return to food CARDIOVASCULAR SYSTEM and to DIABETES
should be gradual, with careful monitoring of MELLITUS.
blood-pressure levels and concentrations of Adipose tissue comprises fat deposited as a
serum ELECTROLYTES. Feeding should consist result of eating more food than is metabolised
mainly of liquids and light foods at first, with by exercise and the bodys basic energy needs.
no heavy meals being taken for several days. Surplus fat can in some circumstances be a use-
ful energy store. For example, hibernating ani-
Fat mals burn off the fat stored during the sum-
A food that has more energy-producing power, mer months and are much leaner when they
weight for weight, than any other. Animal fat is wake up in the spring. Excessive quantities of
a mixture in varying proportions of stearic, adipose tissue result in OBESITY, an increasingly
palmitic, and oleic acids combined with gly- serious problem among all age groups, includ-
cerin. Butter contains about 80 per cent of fat; ing children, in countries with developed
ordinary cream, 20 per cent; and rich cream 40 economies.
per cent whilst olive oil is practically a pure
form of fat. When taken to a large extent in the Fatigue
diet, fat requires to be combined with a certain Tiredness: a physiological state in which
proportion of either CARBOHYDRATE or PRO- muscles become fatigued by the LACTIC ACID
TEIN in order that it may be completely con- accumulating in them as the result of their
sumed, otherwise harmful products, known as activity. For the removal of lactic acid in the
ketones, may form in the blood. Each gram of recovery phase of muscular contraction, oxygen
fat has an energy-producing equivalent of 93 is needed. If the supply of oxygen is not plenti-
Calories (see CALORIE). ful enough, or cannot keep pace with the work
Fats are divided into saturated fats that is, the muscle is doing, then lactic acid accumu-
animal fats and dairy produce; and unsaturated lates and fatigue results. There is also a nervous
fats, which include vegetable oils from soya element in muscular fatigue: it is diminished by
bean, maize and sunflower, and marine oils stimulation of the sympathetic nervous system.
from fish (e.g. cod-liver oil). (See also ADIPOSE (See also MUSCLE.)
TISSUE; LIPID; OBESITY.) Chronic fatigue is a symptom of some ill-
nesses such as ANAEMIA, CHRONIC FATIGUE
Body fat Most of the bodys fat is stored in SYNDROME (CFS), HYPOTHYROIDISM, MONO-
ADIPOSE TISSUE which is mainly sited beneath NUCLEOSIS, MOTOR NEURONE DISEASE (MND),
the skin and around various internal organs. MYASTHENIA GRAVIS, MYALGIC ENCEPHALO-
Some, however, is stored in liver, muscle and MYELITIS (ME) and others. Some drugs may also
other cellular structures such as bone marrow produce a feeling of fatigue.
(see BONE). Various methods can be used to
estimate the bodys fat content but all are Fat Necrosis
indirect and not very accurate, depending as In injury to, or inflammation of, the PANCREAS,
they do on hard-to-measure differences in the fat-splitting enzyme in it may escape into
composition between fat and lean tissues. The the abdominal cavity, causing death of fat-
average body fat of healthy young men and containing cells.
 268 Fatty Degeneration

Fatty Degeneration body temperature is greater than normal (369

As a result of ANAEMIA, interference with blood 378 C).
or nerve supply, or because of the action of
various poisons, body cells may undergo Febrile Convulsion
abnormal changes accompanied by the appear- Convulsion occurring in a child aged six
ance in their substance of fat droplets. months to six years with a high temperature in
which the limbs twitch; he or she may lose con-
Fauces sciousness. The condition is common, with one
The somewhat narrowed opening between the child in 20 suffering from it. It is a result of
mouth and throat. It is bounded above by the immature homeostatic control (see HOMEO-
soft palate, below by the tongue, and on STASIS) and is not usually serious, occurring
either side by the tonsil. In front of, and generally during an infection such as measles or
F behind, the tonsil are two ridges of mucous tonsillitis. The brain and nervous system are
membrane, the anterior and posterior pillars normal in most cases. Treatment is tepid spon-
of the fauces. ging and attention to the underlying cause,
with the child placed in the recovery position. It
Favism is important to rule out more serious illness,
A type of haemolytic ANAEMIA, attacks of which such as MENINGITIS, if the child seems
occur within an hour or two of eating broad particularly ill.
beans (Vicia fava). It is a hereditary disease due
to lack of an essential ENZYME called glucose-6- Feedback Mechanism
phosphate dehydrogenase, which is necessary Many glands which produce HORMONES are
for the continued integrity of the red cell. This influenced by other hormones, particularly
defect is inherited as a sex-linked dominant those secreted by the HYPOTHALAMUS (a con-
trait, and the red cells of patients with this trolling centre in the brain) and the PITUITARY
abnormality have a normal life-span until chal- GLAND. If the amount of hormone produced by
lenged by certain drugs or fava beans when the a gland rises, negative feedback mechanisms
older cells are rapidly destroyed, resulting in operate by instructing the pituitary gland, via
haemolytic anaemia. Fourteen per cent of the hypothalamus, to produce less of the stimu-
African-Americans are affected and 60 per cent lating hormones. This cuts activity in the target
of Yemenite Jews in Israel. The perpetuation of gland. Should the amount of hormone pro-
the gene is due to the greater resistance against duced fall, the feedback mechanism weakens
MALARIA that it carries. Severe and even fatal with the result that the output of stimulating
HAEMOLYSIS has followed the administration of hormones increases.
the antimalarial compounds pamaquine and
primaquine in sensitive individuals. These red Female Genital Mutilation
cells are sensitive not only to fava beans and (FGM)
primaquine but also to sulphonamides, acetani- See CIRCUMCISION.
lide, phenacetin, para-aminosalicyclic acid,
nitrofurantoin, probenecid and vitamin K Feminisation
analogues. The development of a feminine appearance in a
man, often the result of an imbalance in the sex
Favus hormones. Castration, especially before
Another name for honeycomb ringworm. (See puberty, causes feminisation, as may the use of
RINGWORM.) hormones to treat an enlarged PROSTATE
GLAND.
Fear
An emotional condition provoked by danger Femoral
and usually characterised by unpleasant subject- Adjective relating to the FEMUR or the region of
ive feelings accompanied by physiological and the thigh. For example, the femoral nerve,
behavioural changes. The heart rate increases, artery, vein and canal.
sweating occurs and the blood pressure rises.
Sometimes fear of certain events or places may Femur
develop into a phobia: for example, agora- The thigh bone, which is the longest and
phobia, a fear of open spaces. strongest bone in the body. As the upper end is
set at an angle of about 120 degrees to the rest
Febrile of the bone, and since the weight of the body is
Having a FEVER. Describes a patient whose entirely borne by the two femora, fracture of
 Fetus 269

one of these bones close to its upper end is a have hand and facial deformities and are some-
common accident in old people, whose bones times mentally retarded.
are often weakened by osteoporosis (see under
BONE, DISORDERS OF). The femur fits, at its Fetal Blood Sampling
upper end, into the acetabulum of the pelvis, A procedure performed during a mothers
forming the hip-joint, and, at its lower end, labour in which a blood sample is taken from a
meets the tibia and patella in the knee-joint. vein in the scalp of the FETUS. This enables tests
to be performed that indicate whether the fetus
Fenestration is, for example, suffering from a shortage of
A largely obsolete surgical operation to form a oxygen (HYPOXIA). If so, the obstetrician will
new opening in the bony LABYRINTH of the usually accelerate the babys birth.
inner ear in the treatment of deafness caused
by otosclerosis (see under EAR, DISEASES OF). Fetal Transplant F
Nowadays the disorder is usually surgically A procedure in which cells for example, from
treated by STAPEDECTOMY. the pancreas are taken from an aborted FETUS
and then transplanted into the malfunctioning
Fertilisation organ (pancreas) of an individual with a dis-
The process by which male and female gametes order of that organ (in this case, diabetes). The
(spermatozoa and ocytes respectively) fuse to cells from the fetus are intended to take over the
form a zygote which develops, by a complex function of the hosts diseased or damaged cells.
process of cell division and differentiation, into Fetal brain cells have also been transplanted
a new individual of the species. In humans, fer- into brains of people suffering from PARKIN-
tilisation occurs in the FALLOPIAN TUBES. SONISM. These treatments are at an
Sperm deposited in the upper vagina traverse experimental stage.
the cervix and uterus to enter the Fallopian
tube. Many sperm attempt to penetrate the Fetishism
zona pellucida surrounding the ocyte, but This is a form of sexual deviation in which
only one is able to penetrate the ocyte proper the person becomes sexually stimulated by
and this prevents any other sperm from enter- parts of the body, such as the feet, which are
ing. Once the sperm has entered the ocyte, the not usually regarded as erotogenic. Some
two nuclei fuse before the zygote begins to people are sexually aroused by items of
divide. clothing or shoes.

Fertility Rate Fetoscopy

The number of live births that occur in a year Inspection of a FETUS by passing a fibreoptic
for every 1,000 women of childbearing age (this instrument called a fetoscope through the
is usually taken as 1544 years of age). The abdominal wall of a pregnant woman into her
fertility rate in the UK (all ages) was 54.9 in UTERUS. The procedure is usually conducted in
2002 (UK Health Statistics, 2001 edition, The the 18th to 20th week of pregnancy to assess
Stationery Office). the fetus for abnormalities and to take blood
samples to preclude diseases such as HAEMO-
Fester PHILIA, DUCHENNE MUSCULAR DYSTROPHY and
A popular, not a medical, term used to mean sickle-cell ANAEMIA. The procedure should be
any collection or formation of pus. It is applied used only if there is a serious possibility of
to both abscesses and ulcers. (See ABSCESS; abnormality, the presence of which will usually
ULCER; WHITLOW.) have been indicated by other screening tests
such as ULTRASOUND and tests of blood
Festination obtained by (intrauterine) cordocentesis (with-
The involuntary quickening of gait seen drawal of blood by syringe inserted into the
in some nervous diseases, especially in umbilical cord).
PARKINSONISM.
Fetus
Fetal Alcohol Syndrome The name given to the unborn child after the
A disorder of newborn infants that is caused by eighth week of development. Humans, like all
the toxic effects on the growing FETUS of exces- animals, begin as a single cell, the OVUM, in the
sive amounts of alcohol taken by the mother. ovary (see OVARIES). After FERTILISATION with a
Low birth-weight and retarded growth are the SPERMATOZOON, the ovum becomes embedded
main consequences, but affected babies may in the mucous membrane of the UTERUS, its
 270 Fever

covering being known as the decidua. Increase the sides growing forwards from the spinal
in size is rapid, and development of complexity region. In the neck, the growth takes the form
is still more marked. The original cell divides of five arches, similar to those which bear gills
repeatedly to form new cells, and these become in fishes. From the first of these the lower jaw is
arranged in three layers known as the ectoderm, formed; from the second the hyoid bone, all the
mesoderm and endoderm. The first produces arches uniting, and the gaps between them clos-
the skin, brain and spinal cord, and the nerves; ing up by the end of the second month. At this
the second the bones, muscles, blood vessels time the head and neck have assumed quite a
and connective tissues; while the third develops human appearance.
into the lining of the digestive system and the The digestive canal begins as a simple tube
various glands attached to it. running from end to end of the embryo, but it
The embryo develops upon one side of the grows in length and becomes twisted in various
F ovum, its first appearance consisting of a directions to form the stomach and bowels. The
groove, the edges of which grow up and join to lungs and the liver arise from this tube as two
form a tube, which in turn develops into the little buds, which quickly increase in size and
brain and spinal cord. At the same time, a part complexity. The kidneys also appear very early,
of the ovum beneath this is becoming pinched but go through several changes before their final
off to form the body, and within this the endo- form is reached.
derm forms a second tube, which in time is The genital organs appear late. The swell-
changed in shape and lengthened to form the ings, which form the ovary in the female and
digestive canal. From the gut there grows out the testicle (or testis) in the male, are produced
very early a process called the allantois, which in the region of the loins, and gradually descend
attaches itself to the wall of the uterus, develop- to their final positions. The external genitals are
ing into the PLACENTA (afterbirth), a structure similar in the two sexes till the end of the third
well supplied with blood vessels which draws month, and the sex is not clearly distinguish-
nourishment from the mothers circulation via able till late in the fourth month.
the wall of the womb. The blood vessels appear in the ovum even
The remainder of the ovum which within before the embryo. The heart, originally
two weeks of conception has increased to double, forms as a dilatation upon the arteries
about 2 mm (1/12 inch) in size splits into an which later produce the aorta. These two hearts
outer and inner shell, from the outer of which later fuse into one.
are developed two covering membranes, the The limbs appear at about the end of the
chorion and amnion; while the inner consti- third week, as buds which increase quickly in
tutes the yolk sac, attached by a pedicle to the length and split at their ends into five parts, for
developing gut of the embryo. From two weeks fingers or toes. The bones at first are formed of
after conception onwards, the various organs cartilage, in which true bone begins to appear
and limbs appear and grow. The human during the third month. The average period of
embryo at this stage is almost indistinguishable human gestation is 266 days or 280 days from
in appearance from the embryo of other ani- the first day of the last menstrual period. The
mals. After around the middle of the second average birth weight of an infant born of a
month, it begins to show a distinctly human healthy mother (in the UK) is 3,200 g (see
form and then is called the fetus. The property table).
of life is present from the very beginning, The following table gives the average size and
although the movements of the fetus are not weight of the fetus at different periods:
usually felt by the mother until the fifth
month.
Age Length Weight
During the first few days after conception the
4 weeks 5 mm 13 grams
eye begins to be formed, beginning as a cup-
3 months 8 to 9 cm 30 to 60 grams
shaped outgrowth from the mid-brain, its lens
5 months 15 to 25 cm 170 to 340 grams
being formed as a thickening in the skin. It is
7 months 32 to 35 cm 1,360 to 1,820 grams
very soon followed by the beginnings of the
Birth 45 to 60 cm 3,200 grams
nose and ear, both of which arise as pits on the
(See also PREGNANCY AND LABOUR.)
surface, which increase in complexity and are
joined by nerves that grow outward from the
brain. These three organs of sense have practic- Fever
ally their final appearance as early as the begin- Fever, or PYREXIA, is the abnormal rise in body
ning of the second month. TEMPERATURE that frequently accompanies dis-
The body closes in from behind forwards, ease in general.
 Fibreoptic Endoscopy 271

Causes The cause of fever is the release of There is a relative increase in the pulse and
fever-producing proteins (pyrogens) by phago- breathing rates. The tongue is dry and furred;
cytic cells called monocytes and macrophages, the thirst is intense, while the appetite is gone;
in response to a variety of infectious, immuno- the urine is scanty, of high specific gravity and
logical and neoplastic stimuli. The lymphocytes containing a large quantity of solid matter,
(see LYMPHOCYTE) play a part in fever produc- particularly urea. The patient will have a head-
tion because they recognise the antigen and ache and sometimes nausea, and children
release substances called lymphokines which may develop convulsions (see FEBRILE
promote the production of endogenous pyro- CONVULSION).
gen. The pyrogen then acts on the thermo- The fever falls by the occurrence of a CRISIS
regulatory centre in the HYPOTHALAMUS and that is, a sudden termination of the symptoms
this results in an increase in heat generation and or by a more gradual subsidence of the
a reduction in heat loss, resulting in a rise in temperature, technically termed a lysis. If death F
body temperature. ensues, this is due to failure of the vital centres
The average temperature of the body in in the brain or of the heart, as a result of either
health ranges from 369 to 375 C (984 to the infection or hyperpyrexia.
995 F). It is liable to slight variations from
such causes as the ingestion of food, the Treatment Fever is a symptom, and the cor-
amount of exercise, the menstrual cycle, and the rect treatment is therefore that of the under-
temperature of the surrounding atmosphere. lying condition. Occasionally, however, it is also
There are, moreover, certain appreciable daily necessary to reduce the temperature by more
variations, the lowest temperature being direct methods: physical cooling by, for
between the hours of 01.00 and 07.00 hours, example, tepid sponging, and the use of anti-
and the highest between 16.00 and 21.00 pyretic drugs such as aspirin or paracetamol.
hours, with trifling fluctuations during these
periods. Fibre, Dietary
The development and maintenance of heat See ROUGHAGE.
within the body depends upon the metabolic
oxidation consequent on the changes continu- Fibreoptic Endoscopy
ally taking place in the processes of nutrition. In A visualising technique enabling the operator to
health, this constant tissue disintegration is examine the internal organs with the minimum
exactly counterbalanced by the consumption of of disturbance or damage to the tissues. The
food, whilst the uniform normal temperature is procedure has transformed the management of,
maintained by the adjustment of the heat for example, gastrointestinal disease. In chest
developed, and of the processes of exhalation disease, fibreoptic bronchoscopy has now
and cooling which take place, especially from replaced the rigid wide-bore metal tube which
the lungs and skin. During a fever this balance was previously used for examination of the
breaks down, the tissue waste being greatly in tracheo-bronchial tree.
excess of the food supply. The body wastes rap- The principle of fibreoptics in medicine is
idly, the loss to the system being chiefly in the that a light from a cold light source passes down
form of nitrogen compounds (e.g. urea). In the a bundle of quartz fibres in the endoscope to
early stage of fever a patient excretes about three illuminate the lumen of the gastrointestinal
times the amount of urea that he or she would tract or the bronchi. The reflected light is
excrete on the same diet when in health. returned to the observers eye via the image
Fever is measured by how high the tempera- bundle which may contain up to 20,000 fibres.
ture rises above normal. At 41.1 C (106 F) The tip of the instrument can be angulated in
the patient is in a dangerous state of hyperpy- both directions, and fingertip controls are pro-
rexia (abnormally high temperature). If this vided for suction, air insufflation and for water
persists for very long, the patient usually dies. injection to clear the lens or the mucosa. The
The bodys temperature will also rise if oesophagus, stomach and duodenum can be
exposed for too long to a high ambient tem- visualised; furthermore, visualisation of the
perature. (See HEAT STROKE.) pancreatic duct and direct endoscopic cannula-
tion is now possible, as is visualisation of the
Symptoms The onset of a fever is usually bile duct. Fibreoptic colonoscopy can visualise
marked by a RIGOR, or shivering. The skin feels the entire length of the colon and it is now
hot and dry, and the raised temperature will possible to biopsy polyps or suspected carcin-
often be found to show daily variations omas and to perform polypectomy.
namely, an evening rise and a morning fall. The flexible smaller fibreoptic bronchoscope
 272 Fibrillation

has many advantages over the rigid tube, serous cavities like the PLEURA, PERITONEUM,
extending the range of view to all segmental and PERICARDIUM, and forms a thick coat upon
bronchi and enabling biopsy of pulmonary par- the surface of the inflamed membranes. It is
enchyma. Biopsy forceps can be directed well also found in inflamed joints, and in the lung as
beyond the tip of the bronchoscope itself, and a result of pneumonia. (See COAGULATION.)
the more flexible fibreoptic instrument causes
less discomfort to the patient. Fibrinogen
Fibreoptic laparoscopy is a valuable tech- The soluble protein in the blood which is the
nique that allows the direct vizualisation of the precursor of FIBRIN, the substance in blood clot.
abdominal contents: for example, the female
pelvic organs, in order to detect the presence of Fibrinolysis
suspected lesions (and, in certain cases, effect The way in which blood clots are removed from
F their subsequent removal); check on the devel- the circulation. The insoluble protein FIBRIN is
opment and position of the fetus; and test the broken down by the enzyme plasmin (see
patency of the Fallopian tubes. PLASMINOGEN) which is activated at the same
(See also ENDOSCOPE; BRONCHOSCOPE; time as the COAGULATION process of blood.
LARYNGOSCOPE; LAPAROSCOPE; COLONO- There is normally a balance between coagula-
SCOPE.) tion and fibrinolysis; an abnormal increase in
the latter causes excessive bleeding.
Fibrillation
A term applied to rapid contraction or TREMOR Fibrinolytic Drugs
of muscles, and especially to a form of A group of drugs, also known as thrombolytics,
abnormal action of the heart muscle in which with the ability to break down the protein
individual bundles of fibres take up independ- FIBRIN, the prime constituent of blood clots (see
ent action. It is believed to be due to a state of THROMBUS; THROMBOSIS). They are used to
excessive excitability in the muscle associated disperse blood clots that have formed in the
with the stretching which occurs in dilatation vessels of the circulatory system. The group
of the heart. The main causes are ATHERO- includes STREPTOKINASE, alteplase and
SCLEROSIS, chronic rheumatic heart disease and
reteplase. The drugs work by activating PLAS-
hypertensive heart disease (see HEART, DISEASES MINOGEN to form PLASMIN which degrades
OF). Fibrillation is distinguished as atrial or ven-
fibrin and breaks up the blood clot (see
tricular, depending on whether the muscle of COAGULATION).
the atria or of the ventricles is affected. In atrial
fibrillation, the heartbeats and the pulse
become extremely irregular, both as regards
Fibroadenoma
A benign tumour of glandular EPITHELIUM
time and force; when the atrium is fibrillating
containing fibrous elements. The commonest
there is no significant contraction of the atrial
benign tumour is of the breast, often occurring
muscle but the cardiac output is maintained by
in young women.
ventricular contraction. In ventricular fibrilla-
tion there is no significant contractile force, so
that there is no cardiac output. The commonest Fibroblasts
cause is myocardial infarction. Administration Cells distributed widely throughout CONNECT-
IVE TISSUE that produce the precursor sub-
of DIGOXIN, timolol or verapamil may restore
normal rhythm, and in some patients, CARDIO- stances of COLLAGEN, elastic fibres and reticular
VERSION a controlled direct-current electric
fibres.
shock given via a modified defibrillator placed
on the chest wall is effective. Fibrocystic Disease of the
Pancreas
Fibrin See CYSTIC FIBROSIS.
A substance formed in the BLOOD as it clots:
indeed, its formation causes clotting. The sub- Fibroid
stance is produced in threads; after the threads Fibroid, or fibromyoma, is the commonest
have formed a close meshwork through the form of tumour of the uterus (see UTERUS, DIS-
blood, they contract, and produce a dense, EASES OF), and one of the most common
felted mass. The substance is formed not only tumours of the human body. It is composed of a
from shed blood but also from LYMPH which mixture of muscular and fibrous tissue. The
exudes from the lymph vessels. Thus fibrin is tumour may be small or as large as a grapefruit.
found in all inflammatory conditions within Fibroids may cause pain and heavy menstrual
 Fibula 273

bleeding and usually occur in women over 30 Cause There is no investigational evidence
years of age. In some women the fibroid may be of inflammatory, metabolic or structural
small enough to remove surgically but, if it is abnormality, and the problem seems functional
large, a HYSTERECTOMY is often necessary. rather than pathological. SEROTONIN deficiency
Small, symptomless fibroids are no danger and has a significant role in fibromyalgia syndrome.
can be left untreated.
Management Controlled trials have con-
Fibroma firmed the usefulness of low-dose AMITRIPTYL-
A benign tumour comprising mainly CON- INE or DOTHIEPIN together with a graded exer-
NECTIVE TISSUE the substance that surrounds cise programme to increase aerobic fitness. How
body structures, binding them together. this works is still unclear; its efficacy may be due
Examples are neurofibroma, affecting connect- to its normalising effects on the sleep centre or
ive tissue around nerves, and ovarian fibroma pain gating (reduction of pain sensation) at F
which develops around the follicles from which the spinal-cord level. Prognosis is often poor.
eggs (ova) develop in the OVARIES. Unless the Nevertheless, suitable advice and training
fibroma is causing symptoms (as a result of can help most patients to learn to cope better
pressure on surrounding tissues) it does not with their condition and avoid unnecessary
require treatment. If symptoms occur, the investigations and drug treatments.
tumour is removed surgically.
Fibrosarcoma
Fibromyalgia Syndrome A cancer of the CONNECTIVE TISSUE arising in
Symptoms These vary, with pain and fatigue the fibroblasts, stem cells that produce connect-
generally prominent, sometimes causing con- ive tissue cells. The tumours can develop in
siderable disability. Patients can usually dress bone or in soft tissue and occur most com-
and wash independently but cannot cope with a monly in the limbs. Treatment is by surgery or
job or household activities. Pain is mainly axial, RADIOTHERAPY.
but may affect any region. ANALGESICS, NON-
STEROIDAL ANTI-INFLAMMATORY DRUGS Fibrosing Alveolitis
(NSAIDS) and local physical treatments are See ALVEOLITIS.
generally ineffective.
Patients often have a poor sleep pattern, wak- Fibrosis
ing exhausted. Unexplained headache, urinary The formation of fibrous or scar tissue, which is
frequency and abdominal symptoms are com- usually due to infection, injury or surgical
mon, but no cause has been found. Patients operation.
generally score highly on measures of anxiety
and DEPRESSION. Fibromyalgia is not an ideal Fibrositis
description; idiopathic diffuse-pain syndrome Pain, muscular stiffness and inflammation
and non-restorative sleep disorder are increas- affecting the soft tissues of the arm, legs and
ingly preferred terms. trunk. The cause is unknown but may include
Clinical findings are generally unremarkable; immunological factors, muscular strain and
most important is the presence of multiple psychological stress. Treatment is usually
hyperalgesic tender sites (e.g. low cervical spine, palliative.
low lumbar spine, suboccipital muscle, mid
upper trapezius, tennis-elbow sites, upper outer Fibrous Dysplasia
quadrants of buttocks, medial fat pad of knees). A rare disease in which areas of bone are
In fibromyalgia, hyperalgesia (excessive dis- replaced by fibrous tissue (see CONNECTIVE TIS-
comfort) is widespread and symmetrical, but SUE). This renders the bone fragile and liable to
absent at sites normally non-tender. Claims by fracture. It may involve only one bone usually
patients to be tender all over are more likely to the thigh bone or FEMUR or several bones.
be due to fabrication or psychiatric disturbance. This latter form of the disease may be accom-
OSTEOARTHRITIS and periarticular syndrome panied by pigmentation of the skin and the
are much more common and should be early onset of PUBERTY.
excluded, together with other conditions, such
as hypothyroidism (see THYROID GLAND, DIS- Fibrous Tissue
EASES OF), SYSTEMIC LUPUS ERYTHEMATOSUS See CONNECTIVE TISSUE.
(SLE) and inflammatory myopathy (see MUSCLES,
DISORDERS OF), which may present with similar Fibula
symptoms. The slender outer bone of the leg. The head of
 274 Filariasis

this bone articualtes with the TIBIA just below that metabolises TESTOSTERONE into the more
the knee, and at the ANKLE it articulates with potent ANDROGEN, dihydrotestosterone. This
the TALUS bone. action results in a reduction of prostate tissue.
The drug is used to treat an enlarged PROSTATE
Filariasis GLAND, thus improving urinary flow. Its side-
The term used to describe several clinical effects include reduced LIBIDO, and IMPO-
entities caused by one or other of the nematode TENCE. Finasteride offers an alternative to
filariae; these include Wuchereria bancrofti/Bru- PROSTATECTOMY for some men but a signifi-
gia malayi, Onchocerca volvulus, Loa loa, Dra- cant minority do not improve. Women of
cunculus medinensis (DRACONTIASIS or guinea- childbearing age should not handle broken or
worm disease), Mansonella perstans, etc. These crushed tablets.
organisms have widely differing geographical
F distributions. Whereas lymphatic filariasis is Fingerprint
present throughout much of the tropics and The unique pattern of fine ridges in the outer
subtropics, ONCHOCERCIASIS (river-blindness) horny layer of the skin at the front of the tip of
is largely confined to west and central Africa each finger and thumb. The ridges are of three
and southern America. Loaiasis is an infection types: loops (70 per cent), whorls (25 per cent)
of west and central Africa, and dracontiasis and arches (5 per cent). Fingerprint patterns
involves west and central Africa and western are used as a routine forensic test by police
India only. forces to identify individuals. Some patterns
Clinically, the lymphatic filariases character- can indicate that the subject has an inherited
istically cause ELEPHANTIASIS (lymphoedema); disorder.
onchocerciasis gives rise to ophthalmic compli-
cations (river-blindness), rashes and subcu- First Aid
taneous nodules; loaiasis causes subcutaneous Emergency procedures to help an ill or injured
Calabar swellings and subconjunctival person before he or she receives expert medical
involvement; and dracontiasis predisposes to attention or is admitted to hospital. Courses of
secondary bacterial infections (usually involv- instruction in first aid comprise 612 sessions,
ing the lower limbs). Diagnosis is by finding the each of about 2 hours duration. Syllabuses of
relevant filarial nematode, either in blood (day instruction are published by various organisa-
and night films should be examined), or in one tions, the principal ones being the British Red
or other of the body fluids. An EOSINOPHILIA is Cross, the St John Ambulance Association, and
often present in peripheral blood. Serological the St Andrews Ambulance Association. (See
diagnosis is also of value. In onchocerciasis, APPENDIX 1: BASIC FIRST AID; APPENDIX 2:
skin-snips and the Mazotti reaction are valuable ADDRESSES: SOURCES OF INFORMATION,
adjuncts to diagnosis. ADVICE, SUPPORT AND SELF-HELP.)
The mainstay of chemotherapy consists of
diethylcarbamazine (aimed predominantly at Fissure
the larval stage of the parasite). However, iver- A term applied both to clefts of normal anatom-
mectin (not available in the UK) is effective in ical structure and also to small narrow ulcers
onchocerciasis, and metronidazole or one of the occurring in skin and mucous membrane. The
benzimidazole compounds have limited value latter type of fissure occurs especially at the cor-
in dracontiasis. Suramin has been used to kill ners of the mouth and at the anus. (See LIPS;
adult filarial worms. Prevention consists of RECTUM, DISEASES OF.)
eradication of the relevant insect vector.
Fistula
Filaricide An unnatural, narrow channel leading from
A generic term for drugs used to treat filarial some natural cavity such as the duct of a
infections (see FILARIASIS). gland, or the interior of the bowels to the
surface. Alternatively a fistula may be a com-
Filling munication between two such cavities where
The insertion, in denistry, of a specially pre- none should exist as, for example, a direct
pared material into a cavity drilled into a tooth, communication between the bladder and
usually for the treatment of dental caries (see bowel.
TEETH, DISORDERS OF).
Cause Fistulas may be congenital or develop
Finasteride as a result of injury or infection. A SALIVARY
Finasteride is a drug which inhibits the ENZYME fistula may develop between the salivary gland
 Flatulence 275

and the outside of the cheek because of a block- underlying structures but still attached at its
age in the duct from the gland to the mouth. A distal end by a PEDICLE through which it
urinary fistula may be one consequence of a receives its blood supply. The free end may then
fracture of the PELVIS which has damaged the be sutured into a new position to cover a defect
URETHRA. Fistulas of the anus are one of the caused by trauma or excision of diseased tissue.
most common forms, usually the result of infec- A free flap involves detachment of a section of
tion and ABSCESS formation. tissue, often including bone and muscle, to a
distant site where the artery and vein supplying
Treatment As a rule, a fistula is extremely it are anastomosed to adjacent vessels and the
difficult to close, especially after it has persisted tissue is sutured into place. (See RECONSTRUCT-
for some time. The treatment consists in an IVE (PLASTIC) SURGERY.)
operation to restore the natural channel, be it
salivary duct, or urethra, or bowel. This is Flat-Foot F
effected by appropriate means in each locality, Flat-foot, or pes planus, is a deformity of the
and when it is attained the fistula heals quickly foot in which its arch sinks down so that
under simple dressings. the inner edge of the foot comes to rest upon
the ground.
Fit
A popular name for a sudden convulsive SEIZ- Causes The disorder may develop in infancy
URE, although the term is also extended to or occur in adult life, usually resulting from a
include sudden seizures of every sort. During combination of obesity and/or an occupation
the occurrence of a fit of any sort, the chief involving long periods of standing.
object should be to prevent the patient from
doing any harm to him or herself as a result of Symptoms Often none, but there may be
the convulsive movements. The person should pain along the instep and beneath the outer
therefore be laid flat, and the head supported ankle. The foot is stiff and broad, walking is
on a pillow or other soft material. (See CONVUL- tiresome, and the toes turn far out.
SIONS; ECLAMPSIA; EPILEPSY; FAINTING; HYS-
TERIA; STROKE; URAEMIA; APPENDIX 1: BASIC Treatment A change of occupation may be
FIRST AID.) necessary, to one which allows sitting. In early
cases the leg muscles may be strengthened by
Fitness tiptoe exercises performed for ten minutes
An ability to perform daily activities without night and morning. A pad to support the arch
becoming overtired. Fitness is dependent on may have to be worn inside the shoe. Rarely,
strength, flexibility and endurance, and the children may require surgery.
level of an individuals fitness will often depend
on their type of employment and the extent to Flatulence
which they indulge in physical exercise, A collection of gas in the stomach or bowels. In
whether training in the local health club or at the former case the gas is expelled from time to
home or regularly participating in sports. Regu- time in noisy eructations (see ERUCTATION) by
lar fitness improves ones health and well-being. the mouth; in the latter it may produce rum-
Fitness exercises should be matched to a per- blings in the bowels, or be expelled from the
sons age and abilities and there is a health dan- ANUS.
ger if someone regularly exercises beyond their
capabilities. Causes When gas is found in large amount in
the bowels, its production is usually due to fer-
5-Hydroxytryptamine mentation set up by bacteria.
See SEROTONIN.
Treatment Flatulence in the stomach is
Flaccid treated by relieving the DYSPEPSIA which causes
Relaxed or lacking in stiffness. Used to describe it. It may also be relieved, or eased, by the
muscles that are not contracting (or following administration of CARMINATIVES. Flatulence
DENERVATION), and organs for example, the may be aggravated by anxiety. If the flatulence is
penis that are lying loose, empty, or with due to, or aggravated by, the habit of swallow-
wrinkles. (Opposite: firm or erect.) ing air, the patient must try and break the habit.
To reduce intestinal flatulence, a sufferer may
Flap require a change of diet to easily digestible
A section of tissue (usually skin) separated from foods.
 276 Flatus

Flatus STRUATION; MENORRHAGIA.) In the majority of

Gas from the intestines (see INTESTINE) that is cases, flooding is the sign of a miscarriage (see
passed out via the ANUS and formed in the large ABORTION).
intestine as a result of bacteria breaking down
carbohydrate and amino acids in digested food. Flucloxacillin
A PENICILLINASE-resistant PENICILLIN used to
Flavine treat penicillin-resistant staphylococci infection
See ANTISEPTICS. (see also STAPHYLOCOCCUS; ANTIBIOTICS).

Flexible Training Fluconazole

A term applied to the system of postgraduate An oral triazole antifungal drug used to treat
local and systemic infections.
F medical training that allows young doctors to
integrate their domestic commitments with the
training requirements necessary to become a Fluctuation
fully qualified specialist, usually by working A sign obtained from collections of fluid by
part-time. laying the fingers of one hand upon one side
of the swelling, and, with those of the other,
Flexion tapping or pressing suddenly on a distant
point of the swelling. The thrill communi-
The bending of a joint in the SAGITTAL plane.
cated from one hand to the other through the
Usually an anterior movement, it is occasionally
fluid is one of the most important signs of the
posterior, as in the case of the knee-joint. Lat-
presence of an ABSCESS, or of effusion of fluid
eral flexion refers to the bending of the spine in
into joints or into the peritoneal cavity (see
the coronal plane that is, from side to side.
PERITONEUM).

Flexor Flucytosine
A MUSCLE that causes bending of a limb or A synthetic drug used as an intravenous adjunct
other body part. to amphotericin to treat severe systemic fungal
infections such as candidiasis (see CANDIDA) and
Flexure cryptococcosis.
A bend in an organ or body part. The term is
used, for example, to describe the skin on the Fluid Balance
inner aspect of the elbow or knee, as in the The appropriate balance of fluid input and
hepatic flexure of the COLON. output (along with dissolved salts essential for
life) over 24 hours. During this period, about
Floaters 2,500 millilitres (ml) of fluid should be taken in
Particles that appear to be floating in a per- by a 70-kg man and the same amount excreted;
sons field of vision. They move quickly as the of this, 1,500 ml will be drunk, 800 ml will be
eye moves, but when the eye is still they seem in the food eaten, and 200 ml produced by food
to drift. Vision is not usually affected. Most metabolism. Excreted water is made up of
floaters are shadows on the retina from minute 1,500 ml of urine, 800 ml insensible loss and
particles in the vitreous humour (see EYE) 200 ml in the faeces. A 70-kg mans total body
which lies in the main part of the eyeball fluid is 42 litres 60 per cent of body weight.
behind the lens. As a person ages, the jelly-like Intracellular fluid comprises 28 litres, extracel-
vitreous humour usually shrinks a little and lular, 14 litres and blood, 5 litres. Water is con-
becomes detached from the retina; this pro- trolled mainly by the sodium concentration in
duces floaters which vanish over time. If a per- the body fluids via the release of antidiuretic
son notices a sudden cloud of floaters, some- hormone (ADH see VASOPRESSIN) from the
times accompanied by flashes of light, it is posterior part of the PITUITARY GLAND. In ser-
likely that a tear in or detachment of the retina iously ill people, close monitoring of fluid
has occurred. This requires prompt medical intake and output, along with measurements of
attention (see EYE, DISORDERS OF Retinal PLASMA sodium and calcium concentrations, is
detachment). an essential factor in treatment.

Flooding Flukes
A popular name for an excessive blood-stained Flukes are a variety of parasitic worms. (See
discharge from the womb (UTERUS). (See MEN- FASCIOLIASIS.)
 Flutter 277

Flunitrazepam Fluorouracil
A drug with the trade name Rohypnol, fluni- An drug of the antimetabolite group a group
trazepam is one of the BENZODIAZEPINES with a that disrupts normal cell division. Fluorouracil
prolonged action prescribed as a hypnotic (see is used intravenously to treat recurrent and
HYPNOTICS). The British National Formulary inoperable carcinoma of the colon and rectum,
warns that the drug may be particularly subject as well as secondaries from cancer of the breast.
to abuse (see DRUG-ASSISTED RAPE). It can be used topically for some malignant
and premalignant skin lesions. (See
Fluocinolone CYTOTOXIC.)
Fluocinolone is one of the CORTICOSTEROIDS
and is applied to the skin as a cream, lotion or Fluoxetine
ointment. It is more potent than hydro- Better known by its trade name Prozac, this
cortisone. It must not be given by mouth. drug one of the SELECTIVE SEROTONIN- F
REUPTAKE INHIBITORS (SSRIS) has been widely
Fluorescein used, especially in North America, for the
A dye which has the special property of absorb- treatment of depression and anxiety (see MEN-
ing blue-light energy and emitting this energy TAL ILLNESS). Though causing fewer side-effects
as green light. This property is made use of in than TRICYCLIC ANTIDEPRESSANT DRUGS (the
examining the cornea for scratches or ulcera- first such drugs widely used), SSRI drugs
tion; it is also used to detect abnormally perme- should be prescribed with care and should not
able (or leaking) blood vessels in the retina and be stopped abruptly. Unlike benzodiazepine
iris especially in diabetic retinopathy and dis- tranquillisers such as Valium, fluoxetine is not
eases of the macula (see EYE; EYE, DISORDERS OF). addictive, but there have been rare reports of it
allegedly provoking people to acts of violence.
Fluoridation The drug acts by modifying the activities of
See FLUORINE. neurotransmitters, notably DOPAMINE and
SEROTONIN in the brain, thus prolonging the
Fluorine effects of these chemical messengers.
One of the halogen series of elements. In the
form of fluoride it is one of the constituents of Flupenthixol
bone and teeth. Supplementing the daily A tranquilliser used in the treatment of schizo-
intake of fluorine diminishes the incidence of phrenia (see MENTAL ILLNESS).
dental caries (see TEETH, DISORDERS OF). In
America and in Britain, evidence indicates that
people who, throughout their lives, have drunk
Fluphenazine
One of the phenothiazine derivatives, of value as
water with a natural fluorine content of 1 part
an antipsychotic drug. (See also NEUROLEPTICS.)
per million have less dental caries than those
whose drinking water is fluorine-free. All the
available evidence indicates that this is the Flurazepam
See BENZODIAZEPINES.
most satisfactory way of giving fluorine, and
that if the concentration of fluorine in drink-
ing water does not exceed 1 part per million, Flutamide
there are no toxic effects. Several water com- An antiandrogen (see ANDROGEN) drug used in
panies in the UK have added fluoride to the the treatment of cancer of the PROSTATE
public water supply, but opponents of this pol- GLAND, sometimes in conjunction with
icy, who claim that fluoride has serious side- GONADORELIN.
effects, have prevented fluoridation being
introduced nationwide. Fluticasone
An aerosol corticosteroid drug used in the
Fluoroscope prevention and treatment of attacks of ASTHMA.
An apparatus for rendering X-rays visible after Inhaled corticosteroids have few or no systemic
they have passed through the body, by project- side-effects unless given in excessive dosage.
ing them on a screen of calcium tungstate. The
technique is known as fluoroscopy. It provides a Flutter
method of being able to watch, for instance, the The term applied to a form of abnormal cardiac
beating of the heart, or the movements of the rhythm, in which the atria contract at a rate of
intestine after the administration of a barium 200400 beats a minute, and the ventricles
meal. (See also X-RAYS.) more slowly. The abnormal rhythm is the result
 278 Fluvastatin

of a diseased heart. (See HEART, DISEASES OF; Follicular Hormone

FIBRILLATION.) See OESTRADIOL.

Fluvastatin Fomentation
One of the STATINS group of drugs used to (See also POULTICES.) Any warm application to
reduce the levels of LDL-CHOLESTEROL in the the surface of the body in the form of a cloth.
blood and thus help to prevent coronary heart Usually, the fomentation cloth is heated by
disease, which is more prevalent in people with being wrung out of hot water.
raised blood cholesterol levels (see HEART, DIS-
EASES OF). Fomites
A traditional term used to include all articles
Foetus which have been brought into sufficiently close
F See FETUS. contact with a person sick of some infectious
disease to retain the infective material and
Folic Acid spread the disease. For example, clothes, bed-
One of the constituents of the vitamin B com- ding, carpets, toys and books may all be fomites
plex, folic acid derives its name from the fact until they are disinfected.
that it is found in many green leaves, including
spinach and grass. It has also been obtained Fontanelle
from liver, kidney and yeasts. It has proved to Areas on the head on which bone has not yet
be of value in the treatment of macrocytic formed. The chief of these is the anterior fonta-
anaemias (see ANAEMIA), particularly those nelle, situated on the top of the head between
associated with SPRUE and nutritional the frontal and two parietal bones. In shape it is
deficiencies. four-sided, about 25 mm (1 inch) square at the
In order to prevent NEURAL TUBE defects and time of birth, gradually diminishing until it is
cleft lip or palate (see CLEFT PALATE), all women completely covered by bone, which should
planning to become pregnant should be advised happen by the age of 18 months. The pulsa-
to have a diet rich in folic acid in the months tions of the brain can be readily felt through it.
before conception until 13 weeks gestation, or Delay in its closure is particularly found in cases
to take folic acid tablets. of RICKETS, as well as in other states of defective
Recent research has suggested that adequate development. The fontanelle bulges in raised
levels of folic acid can prevent the build-up of intracranial pressure from HYDROCEPHALUS
homocysteine, a compound in the blood and MENINGITIS, and depressed in
closely associated with heart attacks and strokes. DEHYDRATION.
It has been suggested that the official recom-
mendation of 200 micrograms a day in the diet Food
should be doubled. (See APPENDIX 5: VITAMINS.) Mixture of substances containing CARBO-
HYDRATE, FAT, PROTEIN, VITAMINS, TRACE
Folium ELEMENTS and water consumed by animals,
(Plural: folia.) Latin term for leaf: for example, including humans, to provide the necessary
digitalis folium is digitalis leaf. nutrients to maintain the bodys METABOLISM.

Follicle Food Intolerance

Follicle is the term applied to a very small sac or This is divided into food aversion, where a per-
gland: for example, small collections of adenoid son simply avoids a food they dislike; food
tissue in the throat, and the small digestive intolerance, where taking the food causes symp-
glands on the mucous membrane of the toms; and food allergy, where the symptoms are
intestine. due to an immunological reaction. Some cases
of food intolerance are due to idiosyncrasy
Follicle-Stimulating Hormone that is, a genetic defect in the patient, such as
A hormone produced by the anterior PITUITARY alactasia, where the intestine lacks the enzyme
GLAND which stimulates the formation of foll- that digests milk sugar, with the result that
icles in the ovary each menstrual cycle (see individuals so affected develop diarrhoea when
OVARIES; MENSTRUATION) and of spermato- they drink milk. Intolerance to specific foods, as
cytes in the testis (see TESTICLE). It is under distinct from allergy, is probably quite common
hypothalamic control (see HYPOTHALAMUS) and and may be an important factor in the aetiology
in the female there is feedback inhibition by of the IRRITABLE BOWEL SYNDROME (IBS).
oestrogens from the developing follicle. For the diagnosis of true food allergy, it is
 Food Poisoning 279

necessary to demonstrate that there is a repro- Many different types of Salmonella (about
ducible intolerance to a specific food; also, that 2,000) cause food poisoning or ENTERITIS,
there is evidence of an abnormal immuno- from eight hours to three days after ingestion of
logical reaction to it. Occasionally the allergic food in which they have multiplied. S.
response may not be to the food itself but to brendeny, S. enteritidis, S. heidelberg, S. newport
food contaminants such as penicillin, or to food and S. thompson are among those commonly
additives such as tartrazine. There may also be causing enteritis. Salmonella infections are
reactions to foods which have pharmacological common in domesticated animals such as cows,
effects, such as caffeine in strong coffee or his- pigs and poultry whose meat and milk may be
tamine in fermented cheese, or such reactions infected, although the animals may show no
may be due to the irritant effect on the intes- symptoms. Duck eggs may harbour Salmonella
tinal mucosa (especially if it is already diseased) (usually S. typhimurium), arising from surface
by, say, highly spiced curries. contamination with the birds faeces, and foods F
Testing blood and skin for food allergy is containing uncooked or lightly cooked hens
beloved of some alternative practitioners but, in eggs, such as mayonnaise, have been associated
practice, the results of tests do not necessarily with enteritis. The incidence of human S.
agree with what happens when the food is enteritidis infection has been increasing, by
taken. Therefore, a careful history is as useful as more than 15-fold in England and Wales annu-
any test in making a diagnosis. ally, from around 1,100 a year in the early
1980s to more than 32,000 at the end of the
Food Poisoning 1990s, but has since fallen to about 10,000. A
This illness is characterised by vomiting, serious source of infection seems to be poultry
diarrhoea and abdominal pain, and results from meat and hens eggs.
eating food contaminated with metallic or Although Salmonella are mostly killed by
chemical poisons, certain micro-organisms heating at 60 C for 15 minutes, contaminated
or microbial products. Alternatively, the foods food requires considerably longer cooking and,
such as undercooked red kidney beans or fish of if frozen, must be completely thawed before-
the scombroid family (mackerel and tuna) hand, to allow even cooking at a sufficient
may contain natural posions. Food poisoning temperature.
caused by chemical or metallic substances usu- Enteritis caused by Campylobacter jejuni is
ally occurs rapidly, within minutes or a few usually self-limiting, lasting 13 days. Since
hours of eating. Among micro-organisms, bac- reporting of the disease began in 1977, in Eng-
teria are the leading cause of food poisoning, land and Wales its incidence has increased
particularly Staphylococcus aureus, Clostridium from around 1,400 cases initially to nearly
perfringens (formerly Cl. welchii), Salmonella 13,000 in 1982 and to over 42,000 in 2004.
spp., Campylobacter jejuni, and Escherichia coli Outbreaks have been associated with unpasteur-
O157. ised milk: the main source seems to be infected
Staphylococcal food poisoning occurs after poultry.
food such as meat products, cold meats, milk,
custard and egg products becomes contamin- ESCHERICHIA COLI O157 was first identified as a
ated before or after cooking, usually through cause of food poisoning in the early 1980s, but
incorrect handling by humans who carry S. its incidence has increased sharply since, with
aureus. The bacteria produce an ENTEROTOXIN more than 1,000 cases annually in the United
which causes the symptoms of food poisoning Kingdom in the late 1990s. The illness can be
18 hours after ingestion. The toxin can with- severe, with bloody diarrhoea and life-
stand heat; thus, subsequent cooking of threatening renal complications. The reservoir
contaminated food will not prevent illness. for this pathogen is thought to be cattle, and
Heat-resistant strains of Cl. perfringens cause transmission results from consumption of raw
food poisoning associated with meat dishes, or undercooked meat products and raw dairy
soups or gravy when dishes cooked in bulk are products. Cross-infection of cooked meat by
left unrefrigerated for long periods before con- raw meat is a common cause of outbreaks of
sumption. The bacteria are anaerobes (see Escherichia coli O157 food poisoning. Water
ANAEROBE) and form spores; the anaerobic and other foods can be contaminated by
conditions in these cooked foods allow the ger- manure from cattle, and person-to-person
minated spores to multiply rapidly during cool- spread can occur, especially in children.
ing, resulting in heavy contamination. Once Food poisoning associated with fried or
ingested the bacteria produce enterotoxin in the boiled rice is caused by Bacillus cereus, whose
intestine, causing symptoms within 824 hours. heat-resistant spores survive cooking. An
 280 Food Standards Agency

enterotoxin is responsible for the symptoms, applied to aid its delivery or to protect the soft
which occur 28 hours after ingestion and skull of a very premature baby. (See PREGNANCY
resolve after 824 hours. AND LABOUR.)
Viruses are emerging as an increasing cause
of some outbreaks of food poisoning from Forensic Medicine
shellfish (cockles, mussels and oysters). That branch of medicine concerned with mat-
The incidence of food poisoning in the UK ters of law and the solving of crimes, for
rose from under 60,000 cases in 1991 to nearly example, by determining the cause of a death in
79,000 in 2004. Public health measures to con- suspicious circumstances or identifying a crim-
trol this rise include agricultural aspects of food inal by examining tissue found at the scene of a
production, implementing standards of hygiene crime. The use of DNA identification to estab-
in abattoirs, and regulating the environment lish who was present at the scene of the crime
F and process of industrial food production, is now a widely used procedure in forensic
handling, transportation and storage. medicine.

Food Standards Agency Foreskin

An independent agency recently set up by the See PREPUCE.
UK government. The aim is for the agency to
protect consumers interests in every aspect of Formaldehyde
food safety and nutrition. The agency advises The British Pharmacopoeia preparation, for-
ministers and the food industry, conducts maldehyde solution, contains 3438 per cent
research and surveillance, and monitors formaldehyde in water. It is a powerful anti-
enforcement of food safety and hygiene laws. septic, and also has the power to harden the
tissues. The vapour is very irritating to the eyes
Foramen and nose.
The Latin term for a hole. It is especially
applied to natural openings in bones, such as Uses For disinfection it is largely used in the
the foramen magnum, the large opening in the form of a spray; it can also be vaporised by
base of the skull through which the brain and heat. One of its advantages is that it does not
spinal cord are continuous. damage metals or fabrics. In 3 per cent solu-
tion in water it is used for the treatment of
Forced Diuresis warts on the palms of the hands and the soles
A means of encouraging EXCRETION via the of the feet.
KIDNEYS of a compound by altering the pH
and increasing the volume of the urine. Forced Formestane
diuresis is occasionally used after drug over- One of the steroidal AROMATASE INHIBITORS
doses, but is potentially dangerous and so only recently introduced for the treatment of
suitable where proper intensive monitoring of patients with advanced postmenopausal breast
the patient is possible. Excretion of acid com- cancer. It is better tolerated than non-steroidal
pounds, such as salicylates, can be encouraged aromatase inhibitors and acts by blocking the
by raising the pH of the urine to 7585 by conversion of androgens (see ANDROGEN) to
the administration of an alkali such as OESTROGEN in peripheral tissue.
bicarbonate (forced alkali diuresis) and that of
bases, such as AMPHETAMINES, by lowering the Formulary
pH of the urine to 5565 by giving an acid A list of formulae used as drugs and other med-
such as ammonium chloride (forced acid ical preparations. The British National Formu-
diuresis). lary is an authoritative six-monthly publication
containing information and advice on medi-
Forced Feeding cines and drugs. Published jointly by the British
See ENTERAL FEEDING. Medical Association and the Royal Pharma-
ceutical Society of Great Britain, with input
Forceps from the Department of Health, it is distrib-
Surgical instruments with a pincer-like action uted to all NHS doctors by the government. In
which are used, for example, during operations, 2005 a BNF for children was published and
for grasping tissues and other materials. There many hospitals and general practices produce
are many different designs for different uses. formularies for use by doctors working in those
Obstetric forceps are designed to fit around facilities.
the infants head and allow traction to be
 Freudian Theory 281

Fossa when the patient breathes, coughs or speaks.

A term applied to various depressions or holes, This helps the doctor to diagnose whether dis-
both on the surface of the body and in internal orders such as fluid in the pleural cavity or
parts, such as the iliac fossa in each lower corner solidification of a section of the lung have
of the abdomen, and the fossae within the skull occurred.
which lodge the different parts of the brain. Friction fremitus is a grating feeling com-
municated to the hand by the movements of
Fovea lungs or heart when the membrane covering
A small depression. In the EYE this is an area them is roughened, as in PLEURISY or PERI-
near the fundus which contains predominantly CARDITIS. Vocal fremitus means the sensation
cones and is the area with greatest visual acuity felt by the hand when a person speaks; it is
(see also VISION). increased when the lung is more solid than
usual. The thrills felt over a heart affected by F
Fractures valvular disease are also varieties of fremitus.
See BONE, DISORDERS OF Bone fractures.
Frenum
Fraenum Also known as the fraenum or frenulum, this
See FRENUM. comprises the folds of mucous membrane that
anchor the bottom of the tongue to the floor of
Framycetin the mouth.
A broad-spectrum antibiotic derived from
Streptomyces decaris. It is active against a wide Frequency
range of organisms, and is used in drops to treat (1) The number of regular recurrences of an
infections of the eyes and ears. event during a given period of time. Examples
in medicine are the heartbeat, and sound vibra-
Freckles tions in the EAR or vocal cords.
Also known as ephelides, these are small, (2) The word is also used to describe frequent
brown, flat spots on the skin. They occur passage of urine, a symptom that is usually
mostly in blonde or red-haired subjects in caused by disorders in the urinary tract for
exposed areas, and darken on exposure to the example, an infection; or any systemic disease
sun. Melanocytes (see MELANOCYTE) are not which increases the daily output of urine for
increased in the basal layer of the EPIDERMIS. example, DIABETES MELLITUS and DIABETES
INSIPIDUS or disorders of the kidney.
Free Association
A psychoanalytic technique in which the ther- Freudian Theory
apist encourages the patient to follow up a spe- A theory that emotional and allied diseases are
cific line of thought and ideas as they enter his due to a psychic injury or trauma, generally of a
or her consciousness. sexual nature, which did not produce an
adequate reaction when it was received and
Freeze Drying therefore remains as a subconscious or affect
A technique for fixating specimens of tissue, memory to trouble the patients mind. As an
involving a minimum of chemical and physical extension of this theory, Freudian treatment
alteration. The histological specimen is consists of encouraging the patient to tell every-
immersed in a chemical, isopentane, which has thing that happens to be associated with trains
been cooled in liquid air to a temperature just of thought which lead up to this memory, thus
below 200 C. This preserves the tissue securing a purging of the mind from the ori-
instantly without large ice crystals forming ginal affect memory which is the cause of the
these would result in structural damage. The symptoms. This form of treatment is also called
specimen is then dehydrated in a vacuum for psychocatharsis or abreaction.
three days, after which it can be examined using The general term, psychoanalysis, is applied,
a MICROSCOPE. in the first place, to the method of helping the
patient to recover buried memories by free
Fremitus association of thoughts. In the second place, the
Tremors or vibrations in an area of the body, term is applied to the body of psychological
detected by palpating (feeling) with the fingers knowledge and theory accumulated and devised
or the hand or by auscultation (listening). The by Sigmund Freud (18561939) and his fol-
procedure is most commonly used when exam- lowers. The term psychoanalyst has tradition-
ining the chest and assessing what happens ally been applied to those who have undergone
 282 Friction

Freudian training, but Freuds ideas are being the head, and sometimes infection develops
increasingly questioned by some modern known as SINUSITIS (see NOSE, DISORDERS OF).
psychiatrists.
Frontal Lobe
Friction The anterior part of the cerebral hemisphere as
The name given either to the FREMITUS felt, or far back as the central sulcus. It contains the
to the grating noise heard, when two rough sur- motor cortex and the parts of the brain con-
faces of the body move over one another. It is cerned with personality, behaviour and learn-
characteristically obtained over the chest in ing. (See BRAIN.)
cases of dry PLEURISY.
Frontal Sinus
Friedreichs Ataxia One of the airspaces that form the paranasal
F A hereditary disease resembling LOCOMOTOR sinuses (see SINUS) within some of the frontal
ATAXIA, and due to degenerative changes in bones of the skull. These sinuses are lined with
nerve tracts and nerve cells of the spinal cord mucous membrane and open into the nasal
and the brain. It occurs usually in children, or cavity.
at any rate before the 20th year of life, and
affects often several brothers and sisters. Its Frostbite
chief symptoms are unsteadiness of gait, with This results from the action of extreme cold
loss of the knee jerks, followed later by difficul- (below 0 C) on the skin. VASOCONSTRICTION
ties of speech, tremors of the hands, head and results in a reduced blood and hence, oxygen
eyes, deformity of the feet, and curvature of the supply, leading to NECROSIS of the skin and,
spine. There is often associated heart disease. in severe cases, of the underlying tissues.
The sufferer gets gradually worse, but may live, Chiefly affecting exposed parts of the body,
with increasing disability, for 2030 years. such as the face and the limbs, frostbite occurs
especially in people exercising at high altitudes,
Frigidity or in those at risk of peripheral vascular disease,
A term used to describe a lack of interest in such as diabetics (see DIABETES MELLITUS), who
sexual intercourse (COITUS) or the inability to should take particular care of their fingers and
achieve intercourse or ORGASM. Though toes when in cold environments.
applicable to both sexes, frigidity is usually In mild cases the condition sometimes
applied to women with these sexual problems. known as frostnip the skin on exposed parts
of the body, such as the cheeks or nose, becomes
Fringe Medicine white and numb with a sudden and complete
See COMPLEMENTARY AND ALTERNATIVE MEDI- cessation of cold and discomfort. In more
CINE (CAM). severe cases, blisters develop on the frozen part,
and the skin then gradually hardens and turns
Frhlichs Syndrome black until the frozen part, such as a finger, is
A condition in children characterised by obes- covered with a black shell of dead tissue. Swell-
ity, physical sluggishness, and retarded sexual ing of the underlying tissue occurs and this is
development. It is the result of disturbed PITU- accompanied by throbbing and aching. If, as is
ITARY GLAND function. often the case, only the skin and the tissues
immediately under it are frozen, then in a mat-
Frontal ter of months the dead tissue peels off. In the
Describing the anterior part of a body or organ. most severe cases of all, muscles, bone and ten-
don are also frozen, and the affected part
Frontal Bone becomes cold, swollen, mottled and blue or
The bone which forms the forehead and pro- grey. There may be no blistering in these severe
tects the frontal lobes of the brain. Before birth, cases. At first there is no pain, but in time
the frontal bone consists of two halves, and this shooting and throbbing pains usually develop.
division may persist throughout life a deep
groove remaining down the centre of the fore- Prevention This consists of wearing the right
head. Above each eye is a heavy ridge in the clothing and never venturing on even quite
bone, most marked in men; behind this, in the short expeditions in cold weather, particularly
substance of the bone, is a cavity on each side on mountains, without taking expert advice as
(the frontal sinus) which communicates with to what should be worn.
the nose. CATARRH in these cavities produces
the frontal headache characteristic of a cold in Treatment Frostnip is the only form of frost-
 Fungal and Yeast Infections 283

bite that should be treated on the spot. As it Three types of fugue have been identified: (a)
usually occurs on exposed parts, such as the acute anxiety; (b) a manifestation of DEPRES-
face, each member of the party should be on the SION; (c) a manifestation of organic mental state
lookout for it in another. The moment that such as occurs after an epileptic seizure (see
whitening of the skin is seen, the individual EPILEPSY).
should seek shelter and warm the affected part
by covering it with his or her warm hand or a Fumigation
glove until the normal colour and consistency A means of DISINFECTION by the vapour of
of the affected part are restored. In more severe powerful antiseptics.
cases, treatment should only be given in hos-
pital or in a well-equipped camp. In essence Functional Diseases
this consists of warming the affected part, pref- See PSYCHOSOMATIC DISEASES.
erably in warm water, against a warm part of the F
body or warm air. Rewarming should be done Fundus
for spells of 20 minutes at a time. The affected (1) The base of an organ, or that part remote
part should never be placed near an open fire. from its opening.
Generalised warming of the whole body may (2) Point on the retina opposite the pupil
also be necessary, using hot drinks, and putting through which nerve fibres and blood vessels
the victim in a sleeping bag. traverse the retina (see EYE).

Frozen Shoulder Fungal and Yeast Infections

A painful condition of the shoulder accom- These infections, also called mycoses (see
panied by stiffness and considerable limitation MYCOSIS), are common and particularly affect
of movement. The usual age-incidence is the skin or mucosal membranes in, for example,
between 50 and 70. The cause is inflammation the mouth, anus or vagina. Fungi consist of
and contracture of the ligaments and muscles of threadlike hyphae which form tangled masses
the shoulder joint, probably due to overuse. or mycelia common mould. In what is called
Treatment is physiotherapy and local steroid dermatophyte (multicellular fungi) fungal
infections. There is practically always complete infection of the hair, nails and SKIN, these
recovery, even though this may take 1218 hyphae invade the KERATIN. This is usually
months. described as RINGWORM, although no worm is
present and the infection does not necessarily
Fructose occur in rings. PITYRIASIS versicolor and candi-
Fructose is another name for laevulose, or fruit dosis (monoliasis see CANDIDA), called thrush
sugar, which is found along with glucose in when it occurs in the vulva, vagina and mouth,
most sweet fruits. It is sweeter than sucrose are caused by unicellular fungi which reproduce
(cane or beet sugar) and this has led to its use as by budding and are called yeasts. Other fungi,
a sweetener. such as ACTINOMYCOSIS, may cause deep
systemic infection but this is uncommon,
Frusemide occurring mainly in patients with immunosup-
A potent loop diuretic with a rapid onset (30 pressive disorders or those receiving prolonged
minutes), and short duration, of action. (See treatment with ANTIBIOTICS.
THIAZIDES, DIURETICS.)
Diagnosis and treatment Any person with
Fugue isolated, itching, dry and scaling lesions of the
The term literally means flight, and it is used to skin with no obvious cause for example, no
describe the mental condition in which an indi- history of eczema (see DERMATITIS) should be
vidual is suddenly seized with a subconscious suspected of having a fungal infection. Such
motivation to flee from some intolerable reality lesions are usually asymmetrical. Skin scrapings
of everyday existence: this usually involves some or nail clippings should be sent for laboratory
agonising interpersonal relationship. As a rule, analysis. If the lesions have been treated with
fugue lasts for a matter of hours or days, but topical steroids they may appear untypical.
may go on for weeks or even months. During Ultraviolet light filtered through glass (Woods
the fugue the individual seldom behaves in a light) will show up microsporum infections,
particularly odd manner though he or she which produce a green-blue fluorescence.
may be considered somewhat eccentric. When Fungal infections used to be treated quite
it is over there is no remembrance of events effectively with benzoic-acid compound oint-
during the fugue. ment; it has now been superseded by new IMI-
 284 Fungus

DAZOLES preparations, such as CLOTRIMAZOLE, Muscarine is the poisonous constituent of

MICONAZOLE and terbinafine creams. The POL- some species. Within two hours of ingestion,
YENES, NYSTATIN and AMPHOTERICIN B, are the victim starts salivating and sweating, has
effective against yeast infections. If the skin is visual disturbances, vomiting, stomach cramps,
macerated it can be treated with magenta (Cas- diarrhoea, vertigo, confusion, hallucinations
tellanis) paint or dusting powder to dry it out. and coma, the severity of symptoms depending
Refractory fungal infection can be treated on the amount eaten and type of mushroom.
systematically provided that the diagnosis of the Most people recover in 24 hours, with
infection has been confirmed. Terbinafine, imi- treatment.
dazoles and GRISEOFULVIN can all be taken by Magic mushrooms are a variety that con-
mouth and are effective for yeast infections. tains psilocybin, a hallucinogenic substance.
(Griseofulvin should not be taken in pregnancy Children who take such mushrooms may
F or by people with liver failure or porphyria.) develop a high fever and need medical care. In
(See also FUNGUS; MICROBIOLOGY.) adults the symptoms usually disappear within
six hours.
Fungus
A simple plant that is parasitic on other plants Treatment If possible, early gastric lavage
and animals. Included in this group are mil- should be carried out in all cases of suspected
dews, moulds, mushrooms, toadstools and poisoning. Identification of the mushroom
yeasts. Unlike other plants, they do not contain species is a valuable guide to treatment. For
the green pigment chlorophyll. Most of the muscarine poisoning, ATROPINE is a specific
worlds 100,000 different species of fungus are antidote. As stated above, hospital referral is
harmless or even beneficial to humans. Yeasts advisable for people who have ingested poison-
are used in the preparation of food and drinks, ous fungi.
and antibiotics are obtained from some fungi. A
few, however, can cause fatal disease and illness Funiculitis
in humans (see FUNGUS POISONING). Inflammation of the SPERMATIC CORD, usually
arising in men with epididymitis (inflammation
Fungus Poisoning of the EPIDIDYMIS in the TESTICLE). The condi-
Around 2,000 mushrooms (toadstools) grow in tion can be painful. ANTIBIOTICS and
England, of which 200 are edible and a dozen ANALGESICS are effective treatment.
are classified as poisonous. Not all the poison-
ous ones are dangerous. It is obviously better to Funnel Chest
See CHEST DEFORMITIES.
prevent mushroom poisoning by ensuring cor-
rect identification of those that are edible;
books and charts are available. If in doubt, do
Funnybone
Colloquial name for the small area at the back
not eat a fungus. of the elbow where the ULNAR NERVE goes over
Severe poisoning from ingestion of fungi is a prominence at the lower end of the HUMERUS
very rare, since relatively few species are highly bone. If the nerve is hit, acute pain results,
toxic and most species do not contain toxic accompanied by tingling in the forearm and
compounds. The most toxic species are those hand.
containing amatoxins such as death cap (Aman-
ita phalloides); this species alone is responsible Furuncle
for about 90 per cent of all mushroom-related Another term for a boil.
deaths. There is a latent period of six hours or
more between ingestion and the onset of clin- Fusidic Acid
ical effects with these more toxic species. The A valuable antistaphylococcal antibiotic used
small intestine, LIVER and KIDNEYS may be both orally and topically. It is particularly useful
damaged therefore, any patient with gastro- in osteomyelitis (see BONE, DISORDERS OF).
intestinal effects thought to be due to ingestion
of a mushroom should be referred immediately Fusobacterium
to hospital where GASTRIC LAVAGE and treat- A species of gram-negative, rod-shaped BAC-
ment with activated charcoal can be carried out, TERIA. It occurs among the normal flora of the
along with parenteral fluids and haemodialysis human mouth, COLON and reproductive tract.
if the victim is severely ill. In most cases where Occasionally, fusobacterium is isolated from
effects occur, these are early-onset gastrointest- abscesses occurring in the lungs, abdomen and
inal effects due to ingestion of mushrooms con- pelvis. One variety occurs in patients with VIN-
taining gastrointestinal irritants. CENTS ANGINA (trench mouth).
 In LOCOMOTOR ATAXIA or tabes dorsalis, the

G sensations derived from the lower limbs are

blunted, and consequently the movements of
the legs are uncertain and the heels planted
upon the ground with unnecessary force. When
the person tries to turn or stands with the eyes
shut, he or she may fall over. When they walk,
GABA they feel for the ground with a stick or keep
GABA, or gamma aminobutyric acid, is an their eyes constantly fixed upon it.
amino acid (see AMINO ACIDS) that occurs in the In spastic paralysis the limbs are moved with
central nervous system, mainly in the brain tis- jerks. The foot first of all clings to the ground
sue. It is a chemical substance that transmits and then leaves it with a spasmodic movement,
inhibitory impulses from nerve endings across
being raised much higher than is necessary.
synapses to other nerves or tissues. In PARKINSONISM the movements are tremu-
Gag lous, and as the person takes very short steps, he
A device that, when placed between a persons or she has the peculiarity of appearing
teeth, keeps the mouth open. constantly to fall forwards, or to be chasing
themselves.
Gag Reflex In CHOREA the walk is bizarre and jerky, the
Assessment of victims of major trauma must affected child often seeming to leave one leg a
include maintenance of their airways and step behind, and then, with a screwing move-
breathing. Any false teeth, vomitus and foreign ment on the other heel, go on again.
bodies should be removed, and the response to Psychologically based idiosyncracies of gait
digital stimulation of the posterior pharyngeal are usually of a striking nature, quite different
wall the gag reflex assessed. Even with a from those occuring in any neurological condi-
normal gag reflex, the airway may be seriously tions. They tend to draw attention to the
threatened if vomiting occurs. During the ini- patient, and are worse when he or she is
tial stages of resuscitation, careful and constant observed.
supervision of the airway is essential, with a
high-volume sucker immediately available. If Galactocele
the gag reflex is absent or impaired, an A cyst-like swelling in the breast which forms as
endotracheal tube should be inserted (see a result of obstruction in the milk-duct draining
ENDOTRACHEAL INTUBATION). the swollen area.

Gait Galactorrhoea
The way in which an individual walks. Gait This term may refer to unusually copious secre-
may be affected by inherited disorders; by ill- tion of milk from the mammary glands when a
ness especially neurological disorders; by mother is feeding her baby. It is also used to
injury; or by drug and alcohol abuse. Children, describe secretion of milk after the mother has
as a rule, begin to walk between the ages of 12 stopped breast feeding.
and 18 months, having learned to stand before
the end of the first year. If a normal-sized child Galactosaemia
shows no ability to make movements by this A very rare, recessively inherited disease, with
time, the possibility of mental retardation must an incidence of around one in 75,000 births. Its
be borne in mind, and if the power of walking importance lies in the disastrous consequences
is not gained by the time the child is a year and of it being overlooked, and results from the
a half old, RICKETS, CEREBRAL PALSY, or a mal- deficiency of an ENZYME essential for the
formation of the hip-joint must be excluded. metabolism of GALACTOSE. Normal at birth,
In hemiplegia, or PARALYSIS down one side of affected infants soon develop jaundice, vomit-
the body following a STROKE, the person drags ing, diarrhoea, and fail to thrive on starting
the paralysed leg. milk feeds. If the disorder remains
Steppage gait occurs in certain cases of alco- unrecognised, liver disease, cataracts (see EYE,
holic NEURITIS, tertiary SYPHILIS (tabes) and DISORDERS OF) and mental retardation result.
other conditions where the muscles that raise Treatment consists of a lactose-free diet, and
the foot are weak so that the toes droop. The special lactose-free milks are now available.
person bends the knee and lifts the foot high, so
that the toes may clear obstacles on the ground. Galactose
(See DROP-FOOT.) A constituent of lactose, galactose is a simple
 286 Gall

sugar that is changed in the liver to glucose. A Diagnosis Stones are usually diagnosed on
rare genetic metabolic disease, GALACTOSAE- the basis of the patients reported symptoms,
MIA, results in infants being unable to achieve although asymptomatic gall-stones are often an
this conversion because the enzyme necessary incidental finding when investigating another
for the reaction is absent. complaint. Confirmatory investigations include
abdominal RADIOGRAPHY although many
Gall gall-stones are not calcified and thus do not
Another name for BILE. show up on these images; ULTRASOUND scan-
ning; oral CHOLECYSTOGRAPHY which entails
Gall-Bladder a patients swallowing a substance opaque to X-
See LIVER. rays which is concentrated in the gall-bladder;
and endoscopic retrograde cholangiopancrea-
Gall-Bladder, Diseases of tography (ERCP) a technique in which an
The gall-bladder rests on the underside of the ENDOSCOPE is passed into the duodenum and a
G LIVER and joins the common hepatic duct via contrast medium injected into the biliary duct.
the cystic duct to form the common BILE DUCT.
The gall-bladder acts as a reservoir and concen-
trator of BILE, alterations in the composition of
Treatment Biliary colic is treated with bed
rest and injection of morphine-like analgesics.
which may result in the formation of gall-
Once the pain has subsided, the patient may
stones, the most common disease of the gall-
then be referred for further treatment as out-
bladder.
lined below. Acute cholecystitis is treated by
surgical removal of the gall-bladder. There are
Gall-stones affect 22 per cent of women
two techniques available for this procedure:
and 11 per cent of men. The incidence
firstly, conventional cholecystectomy, in which
increases with age, but only about 30 per cent
the abdomen is opened and the gall-bladder cut
of those with gall-stones undergo treatment as
out; and, secondly, laparoscopic cholecystec-
the majority of cases are asymptomatic. There
tomy, in which fibreoptic instruments called
are three types of stone: cholesterol, pigment
endoscopes (see FIBREOPTIC ENDOSCOPY) are
and mixed, depending upon their composition;
introduced into the abdominal cavity via several
stones are usually mixed and may contain cal-
small incisions (see MINIMALLY INVASIVE SUR-
cium deposits. The cause of most cases is not
GERY (MIS)). Laparoscopic surgery has the
clear but sometimes gall-stones will form
advantage of reducing the patients recovery
around a foreign body within the bile ducts or
time. Gall-stones may be removed during
gall-bladder, such as suture material.
ERCP; they can sometimes be dissolved using
BILIARY COLIC Muscle fibres in the biliary sys-
ultrasound waves (lithotripsy) or tablet therapy
tem contract around a stone in the cystic duct
(dissolution chemotherapy). Pigment stones,
or common bile duct in an attempt to expel it.
calcified stones or stones larger than 15 mm in
This causes pain in the right upper quarter of
diameter are not suitable for this treatment,
the abdomen, with nausea and occasionally
which is also less likely to succeed in the over-
vomiting.
weight patient. Drug treatment is prolonged
JAUNDICE Gall-stones small enough to enter
but stones can disappear completely after two
the common bile duct may block the flow of
years. Stones may re-form on stopping therapy.
bile and cause jaundice.
The drugs used are derivatives of bile salts, par-
ACUTE CHOLECYSTITIS Blockage of the cystic
ticularly chenodeoxycholic acid; side-effects
duct may lead to this. The gall-bladder wall
include diarrhoea and liver damage.
becomes inflamed, resulting in pain in the right
upper quarter of the abdomen, fever, and an
increase in the white-blood-cell count. There is Other disorders of the gall-bladder
characteristically tenderness over the tip of the These are rare.
right ninth rib on deep inhalation (Murphys POLYPS may form and, if symptomatic, should
sign). Infection of the gall-bladder may accom- be removed. Malignant change is rare.
pany the acute inflammation and occasionally CARCINOMA of the gall-bladder is a disease of
an EMPYEMA of the gall-bladder may result. the elderly and is almost exclusively associated
CHRONIC CHOLECYSTITIS A more insidious with gall-stones. By the time such a cancer has
form of gall-bladder inflammation, producing produced symptoms, the prognosis is bleak: 80
non-specific symptoms of abdominal pain, nau- per cent of these patients die within one year of
sea and flatulence which may be worse after a diagnosis. If the tumour is discovered early, 60
fatty meal. per cent of patients will survive five years.
 Gangrene 287

Gall-Stones should be prescribed only when the potential

See under GALL-BLADDER, DISEASES OF. benefits outweigh the risks. It is also used for
the prevention of cytomegalovirus infection in
Gamete patients who have had a liver transplant.
A sexual or germ cell: for example, an OVUM or
SPERMATOZOON. Ganglion
This term is used in two senses. In anatomy, it
Gamete Intrafallopian Transfer means an aggregation of nerve cells found in
(GIFT) the course of certain nerves. In surgery, it
See ASSISTED CONCEPTION.
means an enlargement of the sheath of a ten-
don, containing fluid. The latter occurs particu-
larly in connection with the tendons in front of,
Gamgee Tissue and behind, the wrist.
A surgical dressing composed of a thick layer of
cotton-wool between two layers of absorbent
gauze, introduced by the Birmingham surgeon,
Causes The cause of these dilatations on the G
tendon-sheaths is either some irregular growth
Sampson Gamgee (18281886). Gamgee tissue
of the SYNOVIAL MEMBRANE which lines them
has been a registered trademark since 1911.
and secretes the fluid that lubricates their
movements, or the forcing-out of a small pouch
Gamma Aminobutyric Acid of this membrane through the sheath in con-
See GABA.
sequence of a strain. In either case a bag-like
swelling forms, whose connection with the syn-
Gamma Benzene Hexachloride ovial sheath becomes cut off, so that synovial
A drug that is used in the treatment of PEDICU- fluid collects in it and distends it more and
LOSIS and SCABIES.
more.
Gamma-Globulin Symptoms A soft, elastic, movable swelling
Gamma-globulin describes a group of proteins forms, most often on the back of the wrist. It is
present in the blood PLASMA. They are charac- usually small and gives no problems. Some-
terised by their rate of movement in an elec- times weakness and discomfort may develop. A
trical field, and can be separated by the process ganglion which forms in connection with the
of ELECTROPHORESIS. Most gamma-globulins flexor tendons in front of the wrist sometimes
are IMMUNOGLOBULINS. Gamma-globulin attains a large size, and extends down to form
injection provides passive or active immunity another swelling in the palm of the hand.
against HEPATITIS A. (See also GLOBULIN;
IMMUNITY; IMMUNOLOGY.) Treatment Sudden pressure with the thumbs
may often burst a ganglion and disperse its con-
Gamma Rays tents beneath the skin. If this fails, surgical exci-
Short-wavelength penetrating electromagnetic sion is necessary but, as the ganglion may
rays produced by some radioactive compounds. disappear spontaneously, there should be no
More powerful than X-rays, they are used in rush to remove it unless it is causing inconveni-
certain RADIOTHERAPY treatments and to steril- ence or pain.
ise some materials.
Gangrene
Gammexane The death and decay of body tissues caused by a
The proprietary name for a synthetic insecticide deficiency or cessation of the blood supply.
which is a formulation of benzene hexachloride. There are two types: dry and moist. The former
It is active against a large range of insects and is a process of mummification, with the blood
pests, including mosquitoes, fleas, lice, cock- supply of the affected area of tissue stopping
roaches, house-flies, clothes moths, bed-bugs, and the tissue withering up. Moist gangrene is
ants, and grain pests. characterised by putrefactive tissue decay
caused by bacterial infection. The dead part,
Ganciclovir when formed of soft tissues, is called a slough
A drug used in the treatment of life- or sight- and, when part of a bone, is called a
threatening infection with CYTOMEGALOVIRUS sequestrum.
(CMV) in patients whose immune systems (see
IMMUNITY) are compromised. Administered by Causes These include injury especially that
intravenous transfusion, the drug is toxic and sustained in war disease, FROSTBITE, severe
 288 Gargles

burns, ATHEROMA in large blood vessels, and The operation is sometimes still done if the
diseases such as DIABETES MELLITUS and RAY- patient has failed to respond to dietary treat-
NAUDS DISEASE. Gas gangrene is a form that ment and treatment with H2-blocking drugs
occurs when injuries are infected with soil con- (see CIMETIDINE; RANITIDINE) along with anti-
taminated with gas-producing bacilli such as biotics to combat Helicobacter pylori, an
Clostridium welchii, which are found in well- important contributary factor to ulcer devel-
cultivated ground. opment. Partial gastrectomy is usually accom-
panied by VAGOTOMY, which involves cutting
Treatment Dry gangrene must be kept dry, the VAGUS nerve controlling acid secretion in
and AMPUTATION of the dead tissue performed the stomach. Among the side-effects of gastrec-
when a clear demarcation line with healthy tis- tomy are fullness and discomfort after meals;
sue has formed. Wet gangrene requires urgent formation of ulcers at the new junction
surgery and prompt use of appropriate between the stomach and duodenum which
antibiotics. may lead to GASTRITIS and oesophagitis (see
G OESOPHAGUS, DISEASES OF); dumping syn-
Gargles drome (nausea, sweating and dizziness because
Gargling is a process by which various sub- the food leaves the stomach too quickly after
stances in solution are brought into contact eating); vomiting and diarrhoea. The side-
with the throat without being swallowed. The effects usually subside but may need dietary and
watery solutions used for the purpose are called drug treatment.
gargles. Gargles are used in the symptomatic
treatment of infections of the throat: for Gastric
example, sore throat, pharyngitis and Relating to or affecting the STOMACH: for
tonsillitis. example, gastric ulcer.

Gargoylism Gastric Lavage

Also known as Hurlers syndrome, gargoylism is A method of gastric decontamination used in
a rare condition due to lack of a specific the treatment of poisoning. It is not used rou-
ENZYME. It is a progressive disorder usually tinely. Lavage involves the passage of a lubri-
leading to death before the age of 10 years. The cated tube via the mouth and OESOPHAGUS into
affected child is usually normal during the first the stomach. Patients are positioned on their
few months of life; mental and physical side with the head lower than the feet. A small
deterioration then set in. The characteristic fea- quantity of fluid (300 ml) is passed into the
tures include coarse facial features (hence the stomach and the contents then drained out (by
name of the condition), retarded growth, chest gravity) by lowering the end of the tube. This is
deformity, stiff joints, clouding of the cornea repeated until the solution is clear of particulate
(see EYE), enlargement of the liver and spleen, matter. The procedure should be done only by
deafness, and heart murmurs, with mental an experienced health professional.
deterioration. It occurs in about one in 100,000
births. Gastric Ulcer
See STOMACH, DISEASES OF.
Gas
See ANAESTHESIA; CARBON MONOXIDE (CO); Gastrin
NITROUS OXIDE GAS. A hormone produced by the MUCOUS MEM-
BRANE in the pyloric part of the STOMACH. The
Gas Gangrene arrival of food stimulates production of the
See GANGRENE. hormone which in turn stimulates the produc-
tion of gastric juice.
Gastrectomy
A major operation to remove the whole or part Gastritis
of the STOMACH. Total gastrectomy is a rare Inflammation of the STOMACH lining. This
operation, usually performed when a person has may take an acute form when excess alcohol or
cancer of the stomach; the OESPHAGUS is then other irritating substances have been taken,
connected to the DUODENUM. Sometimes can- resulting in vomiting. Chronic gastritis may be
cer of the stomach can be treated by doing a the result of regular smoking and chronic alco-
partial gastrectomy: the use of partial gastrec- holism, or the condition may be caused by the
tomy to treat PEPTIC ULCER used to be com- back flow of BILE from the DUODENUM. The
mon before the advent of effective drug therapy. common cause, however, is chronic infection
 Gauchers Disease 289

with HELICOBACTER PYLORI. Symptoms are these headings. The total length in humans is
vague but victims are likely to develop gastric about 9 metres.
ulcers or sometimes cancer. Atrophic gastritis,
when the mucosal lining of the stomach withers Gastro-Oesophageal Reflux
away, may follow chronic gastritis but some- A disorder in which the contents of the STOM-
times occurs as an autoimmune disorder. ACH back up into the OESOPHAGUS because the
usual neuromuscular mechanisms for prevent-
Gastrocnemius ing this are intermittently or permanently fail-
The large double muscle which forms the chief ing to work properly. If persistent, the failure
bulk of the calf, and ends below in the tendo may cause oesophagitis (see OESOPHAGUS, DIS-
calcaneus. EASES OF). If a person develops HEARTBURN,
regurgitation, discomfort and oesophagitis, the
Gastroduodenostomy condition is called gastro-oesophageal reflux
A surgical operation to join the DUODENUM disease (GORD) and sometimes symptoms are so
to a hole made in the STOMACH wall to cir- serious as to warrant surgery. Gastro- G
cumvent an obstruction in the gut for oesophageal reflux is sometimes associated with
example, PYLORIC STENOSIS or to improve HIATUS HERNIA.
the passage of food from the stomach into the Gastro-oesophageal disease should be diag-
duodenum. nosed in those patients who are at risk of phys-
ical complications from the reflux. Diagnosis is
Gastroenteritis usually based on the symptoms present or by
Inflammation of the STOMACH and intestines monitoring the production of acid using a pH
(see INTESTINE), usually resulting from an acute probe inserted into the oesophagus through the
bacterial or viral infection. The main symptoms mouth, since lesions are not usually visible on
are diarrhoea and vomiting, often accompanied ENDOSCOPY. Severe heartburn, caused by the
by fever and especially in infants DEHYDRA- lining of the oesophagus being damaged by
TION. Although generally a mild disease in acid and PEPSIN from the stomach, is com-
western countries, it is the number-one killer of monly confused with DYSPEPSIA. Treatment
infants in the developing world, with more than should start with graded doses of one of the
15 million children dying annually from the PROTON PUMP INHIBITORS; if this is not effect-
disease in India a situation exacerbated by ive after several months, surgery to remedy the
early weaning and malnutrition. Complications reflux may be required, but the effects are not
may include CONVULSIONS, kidney failure, easily predictable.
and, in severe cases, brain damage.
Gastroscope
Treatment This involves the urgent correc- An endoscopic instrument (see ENDOSCOPE) for
tion of dehydration, using intravenous saline viewing the interior of the STOMACH. Intro-
and dextrose feeds initially, with continuing duced into the stomach via the mouth and
replacement as required. Antibiotics are not OESOPHAGUS, the long flexible instrument (also
indicated unless systemic spread of bacterial called an oesophagogastroduodenoscope)
infection is likely. (See also FOOD POISONING.) transmits an image through a fibreoptic bundle
or by a small video camera. The operator can
Gastroenterostomy see and photograph all areas of the stomach and
An operation performed usually in order to also take biopsy specimens when required. (See
relieve some obstruction to the outlet from the also FIBREOPTIC ENDOSCOPY.)
STOMACH. One opening is made in the lower
part of the stomach; another in a neighbouring Gastrostomy
loop of the small intestine. The two are then An operation on the STOMACH by which, when
stitched together. the gullet is blocked by a tumour or other cause,
an opening is made from the front of the
Gastrointestinal Tract abdomen into the stomach, so that fluid food
The passage along which the food passes, in can be passed into the organ.
which it is digested (see DIGESTION), and from
which it is absorbed by lymphatics and blood Gauchers Disease
vessels into the circulation. The tract consists of A disease characterised by abnormal storage of
the mouth, pharynx or throat, oesophagus or LIPID, particularly in the SPLEEN, central ner-
gullet, stomach, small intestine, and large intes- vous system, BONE MARROW, and LIVER. This
tine, in this order. For details, see articles under results in enlargement of the spleen and the
 290 Gel

liver particularly of the former and Gender is determined by a combination of

ANAEMIA. It runs a chronic course. Diagnosis is genetic and environmental factors, in which the
usually by skin fibroblast glucocerebrosidase influence of family upbringing is an important
assay. Death often results from PNEUMONIA or factor. When physical sexual characteristics are
bleeding. Infantile Gauchers often presents ambiguous, the childs gender identity can usu-
with marked neurological signs of rigid neck ally be established if the child is reared as being
DYSPHAGIA, CATATONIA, hyper-reflexia and low clearly male or female. Should, however, the
IQ. The disease can now be treated with child be confused about its sexual identity, the
enzyme replacement using alglucerase. The uncertainty may continue into adult life. Trans-
annual cost per patient is substantial several sexuals generally experience conflicts of identity
thousand pounds. in childhood, and such problems usually occur
by the age of two years. In this type of iden-
Gel tity disorder, which occurs in one in 30,000
The term applied to a COLLOID substance male births and one in 100,000 female births,
G which is firm in consistency although it contains the person believes that he or she is the victim
much water: for example, ordinary GELATIN. of a biological accident, trapped in a body dif-
ferent from what is felt to be his or her true sex.
Gelatin Treatment is difficult: psychotherapy and
This is derived from COLLAGEN, the chief con- hormone treatment may help, but some
stituent of CONNECTIVE TISSUE. It is a colour- affected individuals want surgery to change
less, transparent substance which dissolves in their bodys sexual organs to match their
boiling water, and on cooling sets into a jelly. innately felt sexual gender. The decision to seek
Such a jelly is a pleasant addition to the invalid a physical sex change raises major social prob-
diet, especially when suitably flavoured, but it is lems for individuals, and ethical problems for
of relatively little nutritive value as not more their doctors. Surgery, which is not always suc-
than one ounce can be taken in the day (i.e. the cessful in the long term, requires careful assess-
amount required to make one pint of jelly). ment, discussion and planning. It is important
Although it is a protein, it is lacking in several to preclude mental illness; results in homo-
of the vital amino acids. The ordinary house- sexual men who have undergone surgery are not
hold stock made from boiling bones contains usually satisfactory. Advice and information
gelatin. Mixed with about two and a half times may be obtained from Gender Identity Con-
its weight of glycerin, gelatin forms a soft sub- sultancy Services.
stance used as the basis for many pastilles and
suppositories. Partially degraded gelatin is General Dental Council
sometimes given as a PLASMA-substitute trans- A statutory body set up by the Dentists Act
fusion for short-term emergency treatment for which maintains a register of dentists (see
patients in SHOCK as a result of a severe blood DENTAL SURGEON), promotes high standards of
or fluid loss from burns or SEPTICAEMIA. dental education, and oversees the professional
conduct of dentists. Membership comprises
Gemeprost elected and appointed dentists and appointed
One of the PROSTAGLANDINS administered lay members. Like other councils responsible
vaginally as pessaries for the medical induction for registering health professionals, the General
of late therapeutic ABORTION. Gemeprost also Dental Council now comes under the umbrella
softens the cervix before surgical abortion, of the new Council for Regulatory Excellence, a
being particularly useful for women in their statutory body. (See APPENDIX 7: STATUTORY
first pregnancy. Prostaglandins induce contrac- ORGANISATIONS.)
tions of the UTERUS while keeping blood loss to
a minimum. General Dental Services
See DENTAL SURGEON.
Gender Identity Disorders
Gender identity is the inner sense of masculin- General Medical Council (GMC)
ity or femininity, and gender role is an indi- A statutory body of elected and appointed med-
viduals public expression of being male, ical practitioners and appointed lay members
female, or a mix (androgynous). Most people with the responsibility of protecting patients
have no difficulty because their gender identity and guiding doctors in their professional prac-
and role are congruous. A person with a gender tice. Set up by parliament in 1858 at the
identity disorder, however, has a conflict request of the medical profession, which was
between anatomical sex and gender identity. concerned by the large numbers of untrained
 General Practitioner (GP) 291

people practising as doctors the GMC is General Practitioner (GP)

responsible for setting educational and profes- A general practitioner (family doctor; family
sional standards; maintaining a register of practitioner) is a doctor working in primary
qualified practitioners; and disciplining doctors care, acting as the first port of professional con-
who fail to maintain appropriate professional tact for most patients in the NHS. There are
standards, cautioning them or temporarily or approximately 35,000 GPs in the UK and their
permanently removing them from the Medical services are accessed by registering with a GP
Register if they are judged unfit to practise. practice usually called a surgery or health
The Council is funded by doctors annual centre. Patients should be able to see a GP
fees and is responsible to the Privy Council. within 48 hours, and practices have systems to
Substantial reforms of the GMCs structure try to ensure that urgent problems are dealt
and functions have been and are still being with immediately. GPs generally have few diag-
undertaken to ensure that it operates effectively nostic or treatment facilities themselves, but can
in todays rapidly evolving medical and social use local hospital diagnostic services (X-rays,
environment. In particular, the Council has blood analysis, etc.) and can refer or admit their G
strengthened its supervisory and disciplinary patients to hospital, where they come under the
functions, and among many changes has supervision of a CONSULTANT. GPs can pre-
proposed the regular revalidation of doctors scribe nearly all available medicines directly to
professional abilities on a periodic basis. The their patients, so that they treat 90 per cent of
Medical Register, maintained by the GMC, is illnesses without involving specialist or hospital
intended to enable the public to identify services.
whom it is safe to approach to obtain medical Most GPs work in groups of self-employed
services. Entry on the Register shows that the individuals, who contract their services to the
doctor holds a recognised primary medical local Primary Care Trust (PCT) see below.
qualification and is committed to upholding Those in full partnership are called principals,
the professions values. Under revalidation but an increasing number now work as non-
requirements being finalised, in addition to principals that is, they are employees rather
holding an initial qualification, doctors wish- than partners in a practice. Alternatively, they
ing to stay on the Register will have to show might be salaried employees of a PCT. The
their continuing fitness to practise according to average number of patients looked after by a
the professional attributes laid down by the full-time GP is 1,800 and the average duration
GMC. of consultation about 10 minutes. GPs need to
Once revalidation is fully established, there be able to deal with all common medical condi-
will be four categories of doctor: tions and be able to recognise conditions that
Those on the Register who successfully show
their fitness to practise on a regular basis.
require specialist help, especially those requiring
urgent action.
Those whose registration is limited, sus- Until the new General Medical Services
pended or removed as a result of the Contract was introduced in 2004, GPs had to
Councils disciplinary procedures. take individual responsibility for providing all
Those who do not wish to stay on the Regis- necessary medical services at all times to their
ter or retain any links with the GMC. patient list. Now, practices rather than indi-
Those, placed on a supplementary list, who
do not wish to stay on the main Register but
viduals share this responsibility. Moreover, the
contract now applies only to the hours between
who want to retain a formal link with the 8.00 a.m. and 6.30 p.m., Mondays to Fridays;
medical profession through the Council. out-of-hours primary care has become the
Such doctors will not be able to practise or responsibility of PCTs. GPs still have an obliga-
prescribe. tion to visit patients at home on weekdays in
case of medical need, but home-visiting as a
General Optical Council proportion of GP work has declined steadily
The statutory body that regulates the profes- since the NHS began. By contrast, the amount
sions of ophthalmic OPTICIAN (optometrist) of time spent attending to preventive care and
and dispensing optician. It promotes high organisational issues has steadily increased. The
standards of education and professional con- 2004 contract for the first time introduced
duct and was set up by the Opticians Act 1958. payment for specific indicators of good clinical
care in a limited range of conditions.
General Paralysis of the Insane A telephone advice service, NHS Direct, was
An outdated term for the tertiary stage of launched in 2000 to give an opportunity for
SYPHILIS. patients to consult a trained nurse who guides
 292 Generic Drug

the caller on whether the symptoms indicate with others) are now obliged by the NHS to
that self-care, a visit to a GP or a hospital Acci- link communally with a number of other GPs
dent & Emergency department, or an ambu- in the locality, to form Primary Care Trusts
lance callout is required. The aim of this service (PCTs). Most have a membership of about 30
is to give the patient prompt advice and to GPs, working within a defined geographical
reduce misuse of the skills of GPs, ambulance area, in addition to the community nurses and
staff and hospital facilities. practice counsellors working in the same area;
links are also made to local council social ser-
Training of GPs Training for NHS general vices so that health and social needs are
practice after qualification and registration as a addressed together. Some PCTs also run
doctor requires a minimum of two years post- ambulance services.
registration work in hospital jobs covering a var- One of the roles of PCTs is to develop
iety of areas, including PAEDIATRICS, OBSTET- primary-care services that are appropriate to the
RICS, care of the elderly and PSYCHIATRY. This is needs of the local population, while also
G followed by a year or more working as a regis- occupying a powerful position to influence the
trar in general practice. This final year exposes scope and quality of secondary-care services.
registrars to life as a GP, where they start to look They are also designed to ensure equity of
after their own patients, while still closely resources between different GP surgeries, so that
supervised by a GP who has him- or herself all patients living in the locality have access to a
been trained in educational techniques. Suc- high quality and uniform standard of service.
cessful completion of summative assessment One way in which this is beginning to hap-
regular assessments during training qualifies pen is through the introduction of more overt
registrars to become GPs in their own right, and CLINICAL GOVERNANCE. PCTs devise and help
many newly qualified GPs also sit the member- their member practices to conduct CLINICAL
ship exam set by the Royal College of General AUDIT programmes and also encourage them to
Practitioners (see APPENDIX 8: PROFESSIONAL participate in prescribing incentive schemes. In
ORGANISATIONS). return, practices receive payment for this work,
A growing number of GP practices offer and the funds are used to improve the services
educational attachments to medical students. they offer their patients.
These attachments provide experience of the
range of medical and social problems com- Generic Drug
monly found in the community, while also A medicinal drug that is sold under its official
offering them allocated time to learn clinical (generic) name instead of its proprietary
skills away from the more specialist environ- (patented brand) name. NHS doctors are
ment of the hospital. advised to prescribe generic drugs where
In addition to teaching commitments, many possible as this enables any suitable drug to be
GPs are also choosing to spend one or two ses- dispensed, saving delay to the patient and
sions away from their practices each week, sometimes expense to the NHS. (See APPROVED
doing other kinds of work. Most will work in, NAMES FOR MEDICINES.)
for example, at least one of the following: a
hospital specialist clinic; a hospice; occu- Genes
pational medicine (see under OCCUPATIONAL Humans possess around 30,000 genes which
HEALTH, MEDICINE AND DISEASES); family- are the biological units of heredity. They are
planning clinics; the police or prison services. arranged along the length of the 23 pairs of
Some also become involved in medical adminis- CHROMOSOMES and, like the chromosomes,
tration, representative medicopolitics or jour- therefore come in pairs (see GENETIC CODE).
nalism. To help them keep up to date with Human beings have 46 chromosomes, compris-
advances and changes in medicine, GPs are ing two sex chromosomes and 44 autosomes,
required to produce personal-development but there is also a mitochondrial chromo-
plans that outline any educational activities some outside the cell nucleus (see CELLS) which
they have completed or intend to pursue during is inherited from the mother.
the forthcoming year. Half of a persons genes come from the father
NHS GPs are allowed to see private patients, and half from the mother, and this mix deter-
though this activity is not widespread (see mines the offsprings characteristics. (A quarter
PRIVATE HEALTH CARE). of a persons genes come from each of the four
grandparents.) Genes fulfil their functions by
Primary Care Trusts (PCTs) Groups of controlling the manufacture of particular pro-
GPs (whether working alone, or in partnership teins in the body. The power that genes have to
 Genetic Code 293

influence the bodys characteristics varies: project; so far, only part of the code has been
broadly, some are dominant (more powerful); translated and this is the part that occurs in the
others are recessive (less powerful) whose func- GENES. Genes are responsible for the PROTEIN
tions are overridden by the former. Genes are synthesis of the cell (see CELLS): they instruct the
also liable to change or mutate, giving the cell how to make a particular polypeptide chain
potential for the characteristics of individuals or for a particular protein.
their offspring to be altered. (See GENETIC Genes carry, in coded form, the detailed spe-
CODE; GENETIC DISORDERS; GENE THERAPY; cifications for the thousands of kinds of protein
HUMAN GENOME.) molecules required by the cell for its existence,
for its enzymes, for its repair work and for its
Gene Testing reproduction. These proteins are synthesised
See GENETIC SCREENING. from the 20 natural AMINO ACIDS, which are
uniform throughout nature and which exist in
Gene Therapy the cell cytoplasm as part of the metabolic pool.
Gene therapy is the transfer of normal GENES The protein molecule consists of amino acids G
into a patient to combat the effects of abnormal joined end to end to form long polypeptide
genes which are causing disease(s). The GEN- chains. An average chain contains 100300
ETIC ENGINEERING technique used is SOMATIC amino acids. The sequence of bases in the
cell gene therapy in which the healthy gene is nucleic acid chain of the gene corresponds in
put into somatic cells that produce other cells some fundamental way to the sequence of
for example, stem cells that develop into amino acids in the protein molecule, and hence
BONE MARROW. Descendants of these altered it determines the structure of the particular pro-
cells will be normal and, when sufficient num- tein. This is the genetic code. Deoxyribonucleic
bers have developed, the patients genetic dis- acid (see DNA) is the bearer of this genetic
order should be remedied. The abnormal gene, information.
however, will still be present in the treated indi- DNA has a long backbone made up of
viduals germ cells (eggs or sperm) so he or repeating groups of phosphate and sugar deoxy-
she can still pass the inherited defect on to suc- ribose. To this backbone, four bases are
ceeding generations. attached as side groups at regular intervals.
Gene therapy is currently used to treat dis- These four bases are the four letters used to spell
orders caused by a fault in a single recessive out the genetic message: they are adenine, thy-
gene, when the defect can remedied by intro- mine, guanine and cystosine. The molecule of
ducing a normal ALLELE. Treating disorders the DNA is made up of two chains coiled
caused by dominant genes is more complicated. round a common axis to form what is called a
CYSTIC FIBROSIS is an example of a disease double helix. The two chains are held together
caused by a recessive gene, and clinical trials are by hydrogen bonds between pairs of bases.
taking place on the effectiveness of using LIPO- Since adenine only pairs with thymine, and
SOMES to introduce the normal gene into the guanine only with cystosine, the sequences of
lungs of someone with the disorder. Trials are bases in one chain fixes the sequence in the
also underway to test the effectiveness of intro- other. Several hundred bases would be con-
ducing tumour-suppressing genes into cancer tained in the length of DNA of a typical gene. If
cells to check their spread. the message of the DNA-based sequences is a
Gene therapy was first used in 1990 to treat continuous succession of thymine, the RIBO-
an American patient. Eleven European medical SOME will link together a series of the amino
research councils (including the UKs) recom- acid, phenylalanine. If the base sequence is a
mended in 1988 that gene therapy should be succession of cytosine, the ribosome will link
restricted to correcting disease or defects, and up a series of prolines. Thus, each amino acid
that it should be limited to somatic cells. Inter- has its own particular code of bases. In fact,
ventions in germ-line cells (the sperm and egg) each amino acid is coded by a word consisting
to effect changes that would be inherited, of three adjacent bases. In addition to carrying
though technically feasible, is not allowed (see genetic information, DNA is able to synthesise
CLONING; HUMAN GENOME). or replicate itself and so pass its information on
to daughter cells.
Genetic Code All DNA is part of the chromosome and so
The message set out sequentially along the remains confined to the nucleus of the cell
human CHROMOSOMES. The human gene map (except in the mitochondrial DNA). Proteins
is being constructed through the work of the are synthesised by the ribosomes which are in
international, collaborative HUMAN GENOME the cytoplasm. DNA achieves control over pro-
 294 Genetic Counselling

tein production in the cytoplasm by directing CLEFT PALATE), the risk of recurrence is
the synthesis of ribonucleic acid (see RNA). Most obtained from population studies. Risks
of the DNA in a cell is inactive, otherwise the include not only the likelihood of having a
cell would synthesise simultaneously every pro- child who is congenitally affected by a disorder,
tein that the individual was capable of forming. but also, for adults, that of being vulnerable to
When part of the DNA structure becomes an adult-onset disease.
active, it acts as a template for the ribonucleic The options for individuals would include
acid, which itself acts as a template for protein taking no action; modifying their behaviour; or
synthesis when it becomes attached to the taking some form of direct action. For those at
ribosome. risk of having an affected child, where prenatal
Ribonucleic acid exists in three forms. First diagnosis is available, this would involve either
messenger RNA carries the necessary message carrying on with reproduction regardless of
for the synthesis of a specific protein, from the risk; deciding not to have children; or deciding
nucleus to the ribosome. Second, transfer to go ahead to have children but opting for
G RNA collects the individual amino acids which prenatal diagnosis. For an adult-onset disorder
exist in the cytoplasm as part of the metabolic such as a predisposition to ovarian cancer, an
pool and carries them to the ribosome. Third, individual may choose to take no action; to take
there is RNA in the ribosome itself. RNA has a preventive measures such as use of the oral con-
similar structure to DNA but the sugar is ribose traceptive pill; to have screening of the ovaries
instead of deoxyribose and uracil replaces the with measures such as ultrasound; or to take
base thymine. Before the ribosome can produce direct action such as removing the ovaries to
the proteins, the amino acids must be lined up prevent ovarian cancer from occurring.
in the correct order on the messenger RNA There are now regional genetics centres
template. This alignment is carried out by throughout the United Kingdom, and patients
transfer RNA, of which there is a specific form can be referred through their family doctor or
for each individual amino acid. Transfer RNA specialists.
can not only recognise its specific amino acid,
but also identify the position it is required to Genetic Disorders
occupy on the messenger RNA template. This These are caused when there are mutations or
is because each transfer RNA has its own other abnormalities which disrupt the code of a
sequence of bases and recognises its site on the gene or set of GENES. These are divided into
messenger RNA by pairing bases with it. The autosomal (one of the 44 CHROMOSOMES
ribosome then travels along the chain of mes- which are not sex-linked), dominant, auto-
senger RNA and links the amino acids, which somal recessive, sex-linked and polygenic
have thus been arranged in the requisite order, disorders.
by peptide bonds and protein is released.
Proteins are important for two main reasons. Dominant genes A dominant character-
First, all the enzymes of living cells are made of istic is an effect which is produced whenever a
protein. One gene is responsible for one gene or gene defect is present. If a disease is due
enzyme. Genes thus control all the biochemical to a dominant gene, those affected are hetero-
processes of the body and are responsible for the zygous that is, they only carry a fault in the
inborn difference between human beings. Sec- gene on one of the pair of chromosomes con-
ond, proteins also fulfil a structural role in the cerned. Affected people married to normal
cell, so that genes controlling the synthesis of individuals transmit the gene directly to one-
structural proteins are responsible for morpho- half of the children, although this is a random
logical differences between human beings. event just like tossing a coin. HUNTINGTONS
CHOREA is due to the inheritance of a domin-
Genetic Counselling ant gene, as is neurofibromatosis (see VON
The procedure whereby advice is given about RECKLINGHAUSENS DISEASE) and familial
the risks of a genetic disorder and the various adenomatous POLYPOSIS of the COLON.
options that are open to the individual at risk. ACHONDROPLASIA is an example of a disorder
This may often involve establishing the diag- in which there is a high frequency of a new
nosis in the family, as this would be a pre- dominant mutation, for the majority of
requisite before giving any detailed advice. affected people have normal parents and sib-
Risks can be calculated from simple Mendelian lings. However, the chances of the children of a
inheritance (see MENDELISM) in many genetic parent with the condition being affected are
disorders. However, in many disorders with a one in two, as with any other dominant charac-
genetic element, such as cleft lip or palate (see teristic. Other diseases inherited as dominant
 Genetic Disorders 295

characteristics include spherocytosis, haemor- DYSTROPHY (see also MUSCLES, DISORDERS OF

rhagic telangiectasia and adult polycystic kid- Myopathy) and nephrogenic DIABETES
ney disease. INSIPIDUS.
If the mother of an affected child has another
Recessive genes If a disease is due to a male relative affected, she is a heterozygote car-
recessive gene, those affected must have the rier; half her sons will have the disease and half
faulty gene on both copies of the chromosome her daughters will be carriers. The sister of a
pair (i.e. be homozygous). The possession of a haemophiliac thus has a 50 per cent chance of
single recessive gene does not result in overt dis- being a carrier. An affected male cannot trans-
ease, and the bearer usually carries this poten- mit the gene to his son because the X chromo-
tially unfavourable gene without knowing it. If some of the son must come from the mother;
that person marries another carrier of the same all his daughters, however, will be carriers as the
recessive gene, there is a one-in-four chance that X chromosome for the father must be transmit-
their children will receive the gene in a double ted to all his daughters. Hence sex-linked reces-
dose, and so have the disease. If an individual sive characteristics cannot be passed from father G
sufferer from a recessive disease marries an to son. Sporadic cases may be the result of a
apparently normal person who is a hetero- new mutation, in which case the mother is not
zygous carrier of the same gene, one-half of the the carrier and is not likely to have further
children will be affected and the other half will affected children. It is probable that one-third
be carriers of the disease. The commonest of of haemophiliacs arise as a result of fresh muta-
such recessive conditions in Britain is CYSTIC tions, and these patients will be the first in the
FIBROSIS, which affects about one child in families to be affected. Sometimes the carrier of
2,000. Approximately 5 per cent of the popula- a sex-linked recessive gene can be identified.
tion carry a faulty copy of the gene. Most of the The sex-linked variety of retinitis pigmentosa
inborn errors of metabolism, such as PHENYL- (see EYE, DISORDERS OF) can often be detected
KETONURIA, GALACTOSAEMIA and congenital by ophthalmoscopic examination.
adrenal hyperplasia (see ADRENOGENITAL SYN- A few rare disorders are due to dominant genes
DROME), are due to recessive genes. carried on the X chromosome. An example of
There are characteristics which may be such a condition is familial hypophosphataemia
incompletely recessive that is, neither com- with vitamin-D-resistant RICKETS.
pletely dominant nor completely recessive
and the heterozygotus person, who bears the Polygenic inheritance In many inherited
gene in a single dose, may have a slight defect conditions, the disease is due to the combined
whilst the homozygotus, with a double dose of action of several genes; the genetic element is
the gene, has a severe illness. The sickle-cell trait then called multi-factorial or polygenic. In this
is a result of the sickle-cell gene in single dose, situation there would be an increased incidence
and sickle-cell ANAEMIA is the consequence of a of the disease in the families concerned, but it
double dose. will not follow the Mendelian (see MENDELISM;
GENETIC CODE) ratio. The greater the number
Sex-linked genes If a condition is sex- of independent genes involved in determining a
linked, affected males are homozygous for the certain disease, the more complicated will be
mutated gene as they carry it on their single X the pattern of inheritance. Furthermore, many
chromosome. The X chromosome carries many inherited disorders are the result of a combin-
genes, while the Y chromosome bears few ation of genetic and environmental influences.
genes, if any, other than those determining DIABETES MELLITUS is the most familiar of such
masculinity. The genes on the X chromosome multi-factorial inheritance. The predisposition
of the male are thus not matched by corres- to develop diabetes is an inherited character-
ponding genes on the Y chromosome, so that istic, although the gene is not always able to
there is no chance of the Y chromosome neu- express itself: this is called incomplete pen-
tralising any recessive trait on the X chromo- etrance. Whether or not the individual with a
some. A recessive gene can therefore produce genetic predisposition towards the disease actu-
disease, since it will not be suppressed by the ally develops diabetes will also depend on
normal gene of the homologous chromosome. environmental factors. Diabetes is more com-
The same recessive gene on the X chromosome mon in the relatives of diabetic patients, and
of the female will be suppressed by the normal even more so amongst identical twins. Non-
gene on the other X chromosome. Such sex- genetic factors which are important in precipi-
linked conditions include HAEMOPHILIA, tating overt disease are obesity, excessive intake
CHRISTMAS DISEASE, DUCHENNE MUSCULAR of carbohydrate foods, and pregnancy.
 296 Genetic Engineering

SCHIZOPHRENIA is another example of the cedure is also used in FORENSIC MEDICINE

combined effects of genetic and environmental whereby any tissue left behind by a criminal at
influences in precipitating disease. The risk of the scene of a crime can be compared genetic-
schizophrenia in a child, one of whose parents ally with the tissue of a suspect. DNA, the gen-
has the disease, is one in ten, but this figure is etic material in living cells, can be extracted
modified by the early environment of the child. from blood, semen and other body tissues. The
technique, pioneered in Britain in 1984, is now
Genetic Engineering widely used.
Genetic engineering, or recombinant DNA
technology, has only developed in the past dec- Genetics
ade or so; it is the process of changing the gen- The science which deals with the origin of the
etic material of a cell (see CELLS). GENES from characteristics of an individual or the study of
one cell for example, a human cell can be HEREDITY.
inserted into another cell, usually a bacterium,
G and made to function. It is now possible to Genetic Screening
insert the gene responsible for the production A screening procedure that tests whether a per-
of human INSULIN, human GROWTH HOR- son has a genetic make-up that is linked with a
MONE and INTERFERON from a human cell into particular disease. If so, the person may either
a bacterium. Segments of DNA for insertion develop the disease or pass it on to his or her
can be prepared by breaking long chains into offspring. When an individual has been found
smaller pieces by the use of restriction to carry a genetically linked disease, he or she
enzymes. The segments are then inserted should receive genetic counselling from an
into the affecting organism by using PLASMIDS expert in inherited diseases.
and bacteriophages (see BACTERIOPHAGE). Genetic screening is proving to be a contro-
Plasmids are small packets of DNA that are versial subject. Arguments are developing over
found within bacteria and can be passed from whether the results of such screenings should be
one bacterium to another. made available to employers and insurance
Already genetic engineering is contributing companies a move that could have adverse
to easing the problems of diagnosis. DNA consequences for some individuals with poten-
analysis and production of MONOCLONAL tially harmful genetic make-ups. (See GENES;
ANTIBODIES are other applications of genetic GENETIC DISORDERS.)
engineering. Genetic engineering has signifi-
cantly contributed to horticulture and agri- Genital Herpes
culture with certain characteristics of one See HERPES GENITALIS.
organism or variant of a species being trans-
fected (a method of gene transfer) into another. Genitalia
This has given rise to higher-yield crops and to The external organs of reproduction. The term
alteration in colouring and size in produce. is usually applied to the external parts of the
Genetic engineering is also contributing to our reproductive system: the VULVA in females and
knowledge of how human genes function, as PENIS and SCROTUM in males. Rarely the sex of
these can be transfected into mice and other an individual may not be apparent from the
animals which can then act as models for gen- genitalia. Genitals develop from a common
etic therapy. Studying the effects of inherited embryonic structure, and disturbances in the
mutations derived from human DNA in these hormone controls of the developing genitalia
animal models is thus a very important and may produce an individual whose external geni-
much faster way of learning about human talia are ambiguous. The condition is known as
disease. intersex. The individual may be HERMAPHRO-
Genetic engineering is a scientific procedure DITE or PSEUDOHERMAPHRODITE.
that could have profound implications for the
human race. Manipulating heredity would be Genito-Urinary Medicine
an unwelcome activity under the control of The branch of medicine that deals with the
maverick scientists, politicians or others in posi- effects of SEXUALLY TRANSMITTED DISEASES
tions of power. (STDS) on the URINARY TRACT, REPRODUCTIVE
SYSTEM and other systems in the body. The spe-
Genetic Fingerprinting cialty overlaps with GYNAECOLOGY (womens
This technique shows the relationships between urinary and reproductive systems) and
individuals: for example, it can be used to prove UROLOGY (mens urinary and reproductive
maternity or paternity of a child. The pro- system).
 Giardiasis 297

Genito-Urinary Tract age, and particularly their social consequences

This consists of the KIDNEYS, ureters (see (see also AGEING).
URETER), URINARY BLADDER and URETHRA
and, in the male, also the genital organs. German Measles
See RUBELLA.
Genome
A complete set of CHROMOSOMES derived from Germ Cell
one parent, or the total gene complement of a Those embryonic cells with the potential to
set of chromosomes. An international study is develop into ova (see OVUM) or spermatozoa (see
well underway to produce a complete map of SPERMATOZOON).
the HUMAN GENOME.
Germ Layer
Genotype Any one of the three discrete varieties of body
All of an individuals genetic information that is tissue that develop in the early stages of growth
encoded in his or her CHROMOSOMES. It also of the EMBRYO. Development of the layers can G
means the genetic information carried by a be followed throughout the embryos stages of
pair of alleles which controls a particular char- growth and specialisation into the bodys full
acteristic. (See GENES.) range of tissues and organs (see ECTODERM;
ENDODERM; MESODERM).

Gentamicin Germs
An antibiotic derived from a species of micro-
See MICROBIOLOGY.
organisms, Micromonospora purpurea. Its main
value is that it is active against certain micro-
organisms such as Pseudomonas pyocyanea, E.
Gerontology
The study of alterations in the body and mind
coli and Aerobacter aerogenes which are not
that occur as a person ages, and the problems
affected by other antibiotics, as well as
that result (see AGEING).
staphylococci which have become resistant to
PENICILLIN.
Gestaltism
A school of psychology based on the concept
Gentian Violet that an individuals sense of wholeness is more
A dye belonging to the rosaniline group. It is a valuable than a piecemeal approach to percep-
useful superficial antiseptic for use on unbroken tion and behaviour. Founded in Germany early
skin. in the 20th century, the schools practitioners
regarded the whole as more than a sum of its
Genu Valgum parts. Aimed at resolving personal problems,
The medical term for knock-knee a deformity the therapy increased subjects self-awareness of
of the lower limbs in such a direction that when all aspects of themselves in their environment.
the limbs are straightened, the legs diverge from
one another. As a result, in walking, the knees Gestation
knock against each other. The amount of Gestation is another name for pregnancy (see
knock-knee is measured by the distance PREGNANCY AND LABOUR).
between the medial malleoli of the ankles, with
the inner surfaces of the knee touching and the GFR
knee-caps facing forwards. The condition is so See GLOMERULAR FILTRATION RATE (GFR).
common in children between the ages of 26
years that it may almost be regarded as a normal Giardiasis
phase in childhood. When marked, or persist- A condition caused by a parasitic organism
ing into later childhood, it can be corrected by known as Giardia lamblia, which is found in
surgery (osteotomy). the duodenum (see INTESTINE) and the upper
part of the small intestine. This organism is
Genu Varum usually harmless, but is sometimes responsible
Genu varum is the medical term for BOW LEG. for causing diarrhoea. The illness develops one
or two weeks after exposure to infection, and
Geriatrics usually starts as an explosive diarrhoea, with the
Now increasingly termed medicine of the eld- passage of pale fatty stools, abdominal pain and
erly, this is a branch of medicine that deals nausea. It responds well to METRONIDAZOLE or
with disorders and diseases associated with old MEPACRINE.
 298 Giddiness

Giddiness lymphatic system) are sometimes called that.

See VERTIGO. While they do not produce secretions, lymph
glands do release white blood cells, an essential
GIFT part of the bodys defence system.
See ASSISTED CONCEPTION.
Glandular Fever
Gigantism See MONONUCLEOSIS.
Excessive growth (mainly in height) caused by
overproduction, during childhood or ado- Glans
lescence, of GROWTH HORMONE by a tumour The term applied to the ends of the PENIS and
of the PITUITARY GLAND. Untreated, the the CLITORIS. In the penis the glans is the distal,
affected individual may die in early adulthood. helmet-shaped part that is formed by the bulb-
Sometimes the tumour appears after the indi- ous corpus spongiosum (erectile tissue). In an
vidual has stopped growing and the result then uncircumcised man the glans is covered by the
G is ACROMEGALY rather than gigantism. foreskin or PREPUCE when the penis is flaccid.
Gilles De La Tourettes Glasgow Coma Scale
Syndrome A method developed by two doctors in Glasgow
Also known as Tourettes syndrome, this is a
hereditary condition of severe and multiple tics that is used to assess the depth of COMA or
unconsciousness suffered by an individual. The
(see TIC) of motor or vocal origin. It usually
starts in childhood and becomes chronic (with scale is split into three groups eye opening,
remissions). With a prevalance of one in 2,000, motor response, and verbal response with the
a dominant gene (see GENES) with variable level of activity within each group given a score.
expression may be responsible. The disorder is A persons total score is the sum of the numbers
scored in each group, and this provides a rea-
associated with explosive vocal tics and grunts,
sonably objective assessment of the patients
occasionally obscene (see COPROLALIA). The
coma state particularly useful when monitor-
patient may also involuntarily repeat the words
ing people who have suffered a head injury. (See
or imitate the actions of others (see PALILALIA).
also PERSISTENT VEGETATIVE STATE (PVS).)
HALOPERIDOL, pimozide (an oral antipsychotic
drug similar to CHLORPROMAZINE hydro-
chloride) and clonidine are among drugs that Glaucoma
may help to control this distressing, but fortu- A group of disorders of the eye characterised by
nately rare, disorder. the intraocular pressure being so high as to
damage the nerve fibres in the retina and the
Gingivitis optic nerve (see EYE) as it leaves the eye en route
Inflammation of the gums (see TEETH, DIS- to the brain. The affected person suffers limita-
ORDERS OF). tion of the field of vision and on examination
the optic disc can be seen to be cupped. The
Gland clinical signs depend on the rate and extent of
A collection of CELLS or an ORGAN with a spe- rise in pressure.
cialised ability to make and secrete chemical Individuals most at risk have a family history
substances such as enzymes and hormones of GLAUCOMA (especially among siblings), are
essential for the normal functioning of the myopic (short-sighted), or have diabetic or thy-
body. Glands are classified into two groups: roid eye disease. People with a strong family
ENDOCRINE and EXOCRINE. The former secrete history of the disease should have regular eye
their products, hormones, straight into the checks, including tonometry, from the age of
bloodstream; the latters secretions are dis- 35 years.
charged through ducts. (These functional dif- Glaucoma is usually classified as being
ferences are the reason why glands have been either open-angle glaucoma or narrow-angle
defined as ductless and ducted.) Examples of glaucoma.
endocrine glands are the adrenals, PITUITARY
GLAND and THYROID GLAND. Exocrine glands Open-angle glaucoma is a chronic,
include SEBACEOUS GLANDS (in the skin) and slowly progressive, usually bilateral disorder. It
the SALIVARY GLANDS in the mouth whose occurs in one in 200 of people over 40 and
enzymes start the digestion of food. The accounts for 20 per cent of those registered
BREASTS or mammary glands are exocrine blind in Great Britain. Symptoms are virtually
glands that secrete milk. Though strictly speak- non-existent until well into the disease, when
ing not a gland, LYMPH nodes (part of the the patient may experience visual problems. It is
 Globin 299

not painful. The characteristic findings are that SYSTEM. Providing support and nutrition to
the intraocular pressure is raised (normal pres- neurones (see NEURON(E)), glia comprises vari-
sure is up to 21 mm Hg) causing cupping of ous cells including oligodendrocytes, astrocytes
the optic disc and a glaucomatous visual-field and ependymal cells. There are around ten
loss. The angle between the iris and the cornea times as many glial cells as neurons and they
remains open. Treatment is aimed at decreas- form about 40 per cent of the total volume of
ing the intraocular pressure initially by drops, the brain and spinal cord, playing an essential
tablets and intravenous drug administration. role in the neurochemical transmission func-
Surgery may be required later. A trabeculec- tion of neurons (see BRAIN).
tomy is an operation to create a channel
through which fluid can drain from the eye in Glibenclamide
a controlled fashion in order to bring the pres- A drug which stimulates the beta cells of the
sure down. PANCREAS to liberate INSULIN, and is used to
treat some patients with DIABETES MELLITUS.
Narrow-angle glaucoma affects one in (See also SULPHONYLUREAS.) G
1,000 people over 40 years of age and is more
common in women. Symptoms may start with Gliclazide
coloured haloes around street lights at night. See SULPHONYLUREAS.
These may then be followed by rapid onset of
severe pain in and around the eye accompanied Gliobastoma
by a rapid fall in vision. One eye is usually A type of brain tumour arising from tissue. It
affected first; this alerts the surgeon so that grows rapidly, destroying brain cells and caus-
action can be taken to prevent a similar attack ing a progressive loss of brain function. The
in the other eye. Treatment must be started as patient suffers from headache as a result of
an emergency with a topical beta blocker (see raised cranial pressure, eventually vomiting
BETA-ADRENOCEPTOR-BLOCKING DRUGS) in regularly and becoming increasingly drowsy.
eye drops with other drugs such as ADRENALINE The prognosis is poor and palliative treatment
or pilocarpine added as necessary. Dorzolamide, is required as surgical removal, radiotherapy
a topical anhydrase inhibitor, can also be used. and chemotherapy are not effective.
ACETAZOLAMIDE, also an anhydrase inhibitor,
can be given by mouth. In an emergency before Glioma
surgery, MANNITOL can be given through an A tumour in the brain or spinal cord, composed
intravenous infusion; this is followed by surgery of neuroglia, which is the special connective tis-
to prevent recurrence. Acute narrow-angle glau- sue that supports the nerve cells and nerve fibres
coma occurs because the peripheral iris is (see GLIA). Low-grade malignant gliomas cause
pushed against the back of the cornea. This symptoms by putting pressure on surrounding
closes off the angle between iris and cornea tissues and organs. Highly malignant gliomas
through which aqueous humour drains out of are usually invasive. Gliomas, like other space-
the eye. Since the aqueous humour cannot occupying tumours in the brain, may present
drain away, it builds up inside the eye causing a with headaches, seizures, neurological symp-
rapid increase in pressure. toms or symptoms of mental disturbance.
Various types of LASER treatment trabecu- Treatment may include surgery, radiotherapy
loplasty (burning the trabecular network); iri- and chemotherapy and should be done in a spe-
dotomy (cutting holes to relieve pressure); and cialist neurological centre. Gliomas tend to
ciliary-body ablation by burning are some- spread within the brain and can be difficult to
times used in preference to surgery. remove surgically.

Gleet Glipizide
Gleet means a chronic form of GONORRHOEA. See SULPHONYLUREAS.

Glenoid Gliquidone
The term applied to the shallow socket on the See SULPHONYLUREAS.
shoulder-blade into which the HUMERUS fits,
forming the shoulder-joint. Globin
A protein which, when it combines with haem,
Glia forms HAEMOGLOBIN the molecule found in
Also called neuroglia, this is the specialised the red blood cell that carries oxygen and car-
connective tissue of the CENTRAL NERVOUS bon dioxide.
 300 Globulin

Globulin middle ear. It also supplies the PAROTID GLAND

A class of proteins which are insoluble in water and one of the muscles on the side of the
and alcohol and soluble in weak salt solution. throat.
(See also GAMMA-GLOBULIN.)
Glottis
Globus The narrow opening at the upper end of the
A term applied generally to any structures of LARYNX. The glottis is made up of the true vocal
ball shape, but especially to the sensation of a cords. (See AIR PASSAGES; CHOKING.)
ball in the throat causing choking, which forms
a common symptom of acute anxiety (globus Glucagon
hystericus). A hormone secreted by the alpha cells of the
islets of Langerhans in the PANCREAS, which
Glomerular Filtration Rate (GFR) increases the amount of glucose in the blood.
Each of the two KIDNEYS filters a large volume This it does by promoting the breakdown of
G of blood 25 per cent of cardiac output, or liver GLYCOGEN (glycogenolysis). It is secreted
around 1,300 ml through its two million in response to a lowered blood sugar and is used
glomeruli (see GLOMERULUS) every minute. The therapeutically to treat HYPOGLYCAEMIA.
glomeruli filter out cell, protein, and fat-free
fluid which, after reabsorption of certain chem- Glucocorticoids
icals, is excreted as urine. The rate of this ultra- One of the two main groups of CORTICO-
filtration process, which in health is remarkably STEROIDS. CORTISOL, CORTISONE and corticos-
constant, is called the glomerular filtration rate terone are part of this group and are essential
(GFR). Each day nearly 180 litres of water plus for the body to utilise CARBOHYDRATE, FAT and
some small molecular-weight constituents of PROTEIN in particular, when the body is react-
blood are filtrated. The GFR is thus an indica- ing to stress. Glucocorticoids occur naturally
tor of kidney function. The most widely used but can be synthesised, and they have strong
measurement is CREATININE clearance and this anti-inflammatory properties, being used to
is assessed by measuring the amount of creati- treat conditions in which inflammation is a
nine in a 24-hour sample of urine and the part.
amount of creatinine in the plasma; a formula is
applied that gives the GFR. Gluconeogenesis
The formation of sugar from amino acids in the
Glomerulitis LIVER.
See KIDNEYS, DISEASES OF.
Glucose
Glomerulonephritis Glucose, also known as dextrose or grape sugar,
See KIDNEYS, DISEASES OF. is the form of sugar found in honey and in
grapes and some other fruits. It is also the form
Glomerulus of sugar circulating in the bloodstream, and the
A small knot of blood vessels about the size of a form into which all sugars and starches are con-
grain of sand, of which around 1,000,000 are verted in the small INTESTINE before being
found in each of the two KIDNEYS, and from absorbed. Glucose is a yellowish-white crystal-
which the excretion of fluid out of the blood line substance soluble in water and having the
into the tubules of the kidney takes place. property of turning a ray of polarised light to
the right. It is often given to patients orally or,
Glossitis sometimes, intravenously as an easily assimi-
Inflammation of the tongue. Causes include lated form of CARBOHYDRATE. It has the further
ANAEMIA, CANDIDA infection and dietary (par- practical advantage in this context of not being
ticularly vitamin) deficiencies. The condition nearly as sweet-tasting as cane sugar and there-
may also occur as a result of friction of the fore relatively large amounts can be consumed
tongue against the sharp edge of a tooth. without sickening the patient.

Glossopharyngeal Glucose-6-Phosphate
The glossopharyngeal nerve is the ninth cranial Dehydrogenase
nerve, which in the main is a SENSORY nerve, An ENZYME that performs an essential function
being the nerve of taste in the posterior third of in the metabolism of CARBOHYDRATE. A
the tongue and the nerve of general sensation deficiency in this enzyme acronym G6PD
for the whole upper part of the throat and results in the breakdown of ERYTHROCYTES
 Glyco- 301

(HAEMOLYSIS), usually in the presence of oxi- who are debarred from starchy and sugary
dants (see OXIDANT) such as infections or drugs. foods.
The deficiency disorder is a hereditary condi- It is also responsible for certain forms of what
tion in which the enzyme is absent. The condi- is now known as the MALABSORPTION SYN-
tion, characterised by pallor, rigors and pain in DROME. In patients with this condition, an
the loin, is divided into African, European essential part of treatment is a gluten-free diet.
(including FAVISM) and Oriental types. Suf- (See also COELIAC DISEASE.)
ferers should avoid substances that trigger
haemolysis. Acute episodes are best treated Gluteus
symptomatically. Three gluteal muscles form each buttock. The
gluteus maximus is the large, powerful muscle
Glucose-Tolerance Test that gives the buttocks their rounded shape.
A way of assessing the bodys efficiency at The remaining two muscles are the gluteus
metabolising GLUCOSE. The test is used in the medius and gluteus minimus; together the
diagnosis of DIABETES MELLITUS. The patient is three muscles are responsible for moving the G
starved for up to 16 hours, after which he or she thigh.
is fed glucose by mouth. The concentrations of
glucose in the blood and urine are then meas- Glycerin
ured at half-hour intervals over a period of two Glycerin, or glycerol, is an alcohol, C3H8O3,
hours. which occurs naturally in combination with
organic acids in the form of fats or triglycerides.
Glucoside It is a clear, colourless, thick liquid of sweet
A GLYCOSIDE formed from GLUCOSE. taste. It dissolves many substances, and absorbs
water effectively.
Glue Ear
Another name for secretory otitis media (see Uses Glycerin has many and varied uses.
EAR, DISEASES OF). Numerous substances, such as carbolic acid,
tannic acid, alum, borax, boric acid and
Glue Sniffing starch, are dissolved in it for application to the
See SOLVENT ABUSE. body. It is frequently applied along with other
remedies to inflamed areas for its action in
Glutamate extracting fluid and thus diminishing
An amino acid (see AMINO ACIDS) which, along inflammation.
with aspartate, is a major excitatory chemical
neurotransmitter method of communication Glycerol
between neurones (see NEURON(E)) in the cen- Another name for GLYCERIN.
tral nervous system. The two amino acids are
found in the cortex and cerebellum of the Glyceryl Trinitrate
BRAIN and in the SPINAL CORD. Also known as trinitrin and nitroglycerin, this is
a drug used in the treatment of ANGINA PEC-
Glutaminase TORIS and left ventricular failure of the heart.
An ENZYME occurring in the KIDNEYS which It is normally given as a sublingual tablet or
catalyses the breakdown of glutamine (see spray, though percutaneous preparations may
AMINO ACIDS) to ammonia a phase in the be useful in the prophylaxis of angina particu-
production of the metabolic waste product, larly for patients who suffer attacks at rest, and
UREA. especially at night. Sublingually it provides
rapid symptomatic relief of angina, but is only
Gluteal effective for 2030 minutes. It is a potent vaso-
The region of the buttock and the structures dilator, and this may lead to unwanted side-
situated in it, such as the gluteal muscles (see effects such as flushing, headache, and postural
GLUTEUS), arteries, and nerves. HYPOTENSION. Its antispasmodic effects are also
valuable in the treatment of ASTHMA, biliary
Gluten and renal colic, and certain cases of VOMITING.
The constituent of wheat-flour which forms an (See also COLIC.)
adhesive substance on addition of water, and
allows the raising of bread. It can be separated Glyco-
from the starch of flour, and being of a protein A prefix meaning of the nature of, or contain-
nature is used to make bread for those diabetics ing, sugar.
 302 Glycogen

Glycogen The cells produce the main constituents of

Glycogen, or animal starch, is a CARBO- MUCUS.
HYDRATE substance found specially in the liver,
as well as in other tissues. It is the form in Goitre
which carbohydrates taken in the food are Goitre is a term applied to a swelling in the
stored in the liver and muscles before they are front of the neck caused by an enlargement of
converted into GLUCOSE as the needs of the the THYROID GLAND. The thyroid lies between
body require. the skin and the front of the windpipe and in
health is not large enough to be seen. The four
Glycoproteins main varieties of goitre are the simple goitre, the
Compounds comprising a PROTEIN and a nodular, the lymphadenoid goitre and the toxic
CARBOHYDRATE, such as mucins, mucoid and goitre. (See THYROID GLAND, DISEASES OF.)
amyloid.
Gold Salts
G Glycoside These are used in the treatment of RHEUMA-
A compound of a sugar and a non-sugar unit. TOID ARTHRITIS. Gold may be administered in
Glycosides are widespread throughout nature various forms for example, sodium aurothi-
and include many important drugs such as omalate. It is injected in very small doses intra-
DIGOXIN. muscularly and produces a reaction in the
affected tissues which leads to their scarring and
Glycosylated Haemoglobin healing. Auranofin is a gold preparation that
(HbA1c) can be given orally; if no response has been
This forms a small proportion of the total achieved within six months the drug should be
HAEMOGLOBIN in the blood. It differs from the stopped. It is less effective than gold given by
major component, HbA, in that it has a glucose intramuscular injection. If gold is administered
group attached. The rate of synthesis of HbA1c in too large quantities, skin eruptions, albu-
is a function of the blood-glucose concentra- minuria (see PROTEINURIA), metallic taste in the
tion, and since it accumulates throughout the mouth, JAUNDICE, and feverishness may be
life span of the red blood cell normally 120 produced, so that it is necessary to prolong a
days the concentration of HbA1c is related to course of this remedy over many months in
the mean blood-glucose concentration over the minute doses. Routine blood and urine tests are
past 34 months. It is thus a useful indicator of also necessary in order to detect any adverse or
medium-term diabetic control (see DIABETES toxic effect at an early stage.
MELLITUS) a good target range would be a
concentration of 58 per cent. When interpret- Golfers Elbow
ing the HbA1c level, however, it is important to A term applied to a condition comparable to
remember that wide fluctuations in blood- tennis elbow. It is not uncommon in the left
glucose concentration, together with ANAEMIA elbow of right-handed golfers who catch the
or a reduced ERYTHROCYTES life span, may give head of their club in the ground when making a
misleading results. duff shot.

Glycosuria Gonad
The presence of sugar in the urine. By far the A gland which produces a gamete that is, an
most common cause of glycosuria is DIABETES ovary (see OVARIES) or a testis (see TESTICLE).
MELLITUS, but it may also occur as a result of a
lowered renal threshold for sugar when it is Gonadorelin
called renal glycosuria, and is not indicative of A hormone that stimulates the PITUITARY
disease. Measurements of the amounts of sugar GLAND to secrete three hormones: gonado-
in the urine is a standard method used by trophic, luteinising and follicle-stimulating.
patients (and health professionals) to assess the Gonadorelin can be made artificially and given
stability of treatment for diabetes mellitus, by intravenous injection. It is used to stimulate
indicating whether adjustment is required in the OVARIES when treating infertile women, and
the hypoglycaemic (sugar-lowering) agents they to investigate suspected disease of the HYPO-
are taking. THALAMUS. Analogues of the hormone (buser-
elin and goserelin) are chemically similar and
Goblet Cell can be used to suppress release of gonadorelin,
A columnar secretory cell occurring in the EPI- so cutting the production of pituitary hor-
THELIUM of the respiratory and intestinal tracts. mones. The two analogues are given to treat
 Gonorrhoea 303

ENDOMETRIOSIS, breast cancer (see BREASTS, MEN After an incubation period of 210 days,
DISEASES OF) and prostate cancer (see PROSTATE irritation in the urethra, scalding pain on
GLAND, DISEASES OF). passing water, and a viscid yellowish-white dis-
charge appear; the glands in the groin often
Gonadotrophins enlarge and may suppurate. The urine when
Gonadotrophins, or gonadotrophic hormones, passed is hazy and is often found to contain
are hormones that control the activity of the yellowish threads of pus visible to the eye. After
gonads (i.e. the testes and ovaries). In the male some weeks, if the condition has become
they stimulate the secretion of TESTOSTERONE chronic, the discharge is clear and viscid, there
and the production of spermatozoa (see SPERM- may be irritation in passing urine, and various
ATOZOON); in the female they stimulate the forms of inflammation in neighbouring organs
production of ova (see OVUM) and the secretion may appear the TESTICLE, PROSTATE GLAND
of OESTROGENS and PROGESTERONE. There are and URINARY BLADDER becoming affected. At a
two gonadotrophins produced by the PITUIT- still later stage the inflammation of the urethra
ARY GLAND. CHORIONIC GONADOTROPHIC is apt to lead to gradual formation of fibrous G
HORMONE is produced in the PLACENTA and tissue around this channel. This contracts and
excreted in the urine. produces narrowing, so that urination becomes
difficult or may be stopped for a time altogether
Gonococci (the condition known as stricture). Inflamma-
A bacterium of the species responsible for the tion of some of the joints is a common compli-
sexually transmitted disease GONORRHOEA. cation in the early stage the knee, ankle, wrist,
and elbow being the joints most frequently
Gonorrhoea affected and this form of rheumatism is very
Gonorrhoea is an inflammatory disease caused intractable and liable to lead to permanent
by Neisseria gonococcous, affecting especially the stiffness. The fibrous tissues elsewhere may also
mucous membrane of the URETHRA in the male develop inflammatory changes, causing pain in
and that of the VAGINA in the female, but the back, foot, etc. In occasional cases, during
spreading also to other parts. It is the most the acute stage, SEPTICAEMIA may develop, with
common of the SEXUALLY TRANSMITTED DIS- inflammation of the heart-valves (ENDOCARD-
EASES (STDS). According to the WHO, 200 mil- ITIS) and abscesses in various parts of the body.
lion new cases are notified annually in the The infective matter occasionally is inoculated
world. In the UK the incidence has been declin- accidentally into the eye, producing a very
ing since 1991; in 1999 the rate per million of severe form of conjunctivitis: in the newly born
population was 385 for males (599.4 in 1991) child this is known as ophthalmia neonatorum
and 171.3 for females (216.5 in 1991). and, although now rare in the UK. has in the
past been a major cause of blindness (see EYE,
Causes The disease is directly contagious DISORDERS OF).
from another person already suffering from it WOMEN The course and complications of the
usually by sexual intercourse, but occasionally disease are somewhat different in women. It
conveyed by the discharge on sponges, towels or begins with a yellow vaginal discharge, pain on
clothing as well as by actual contact. The gono- urination, and very often inflammation or
coccus is found in the discharge expressed from abscess of the Bartholins glands, situated close
the urethra, which may be spread as a film on a to the vulva or opening of the vagina. The chief
glass slide, suitably stained, and examined seriousness, however, of the disease is due to the
under the microscope; or a culture from the spread of inflammation to neighbouring
discharge may be made on certain bacterio- organs, the UTERUS, FALLOPIAN TUBES, and
logical media and films from this, similarly OVARIES, causing permanent destructive
examined under the microscope. Since dis- changes in these, and leading occasionally to
charges resembling that of gonorrhoea accom- PERITONITIS through the Fallopian tube with a
pany other forms of inflammation, the identifi- fatal result. Many cases of prolonged ill-health
cation of the organism is of great importance. A and sterility or recurring miscarriages are due to
gram-stained smear of urethral discharge these changes.
enables rapid identification of the gonococcus
in around 90 per cent of men. Treatment The chances of cure are better the
earlier treatment is instituted. PENICILLIN is
Symptoms These differ considerably, accord- the antibiotic of choice but unfortunately
ing to whether the disease is in an acute or a the gonococcus is liable to become resistant
chronic stage. to this. In patients who are infected with
 304 Good Medical Practice

penicillin-resistant organisms, one of the other In patients prone to recurrent or particularly

antibiotics (e.g. cefotaxime, ciprofloxacin or severe attacks, long-term prophylaxis with
spectinomycin) is used. In all cases it is essential ALLOPURINOL is indicated, especially when
that bacteriological investigation should be car- associated with kidney disease. This drug,
ried out at weekly intervals for three or four which has few side-effects, lowers the serum
weeks, to make sure that the patient is cured. urate concentration by preventing the forma-
Patients attending with gonorrhoea are asked if tion of uric acid. A sensible weight-reducing
they will agree to tests for other sexually trans- diet is usually helpful.
mitted infections, such as HIV (see AIDS/HIV)
and for assistance in contact tracing. GP
See GENERAL PRACTITIONER (GP).
Good Medical Practice
Guidelines for doctors on the provision of good Graft
medical care laid down by the GENERAL MED- The term applied to a piece of tissue removed
G ICAL COUNCIL (GMC). from one person or animal and implanted in
another, or the same, individual in order to
Gout remedy some defect. Skin grafts are commonly
A term used to describe several disorders associ- used, and artificial skin for grafting has recently
ated with a raised concentration of URIC ACID been developed. Bone grafts are also used to
in the blood, of which various forms of replace bone which has been lost by disease: for
inflammatory disease and kidney disease are example, a portion of rib is sometimes removed
the most important. The condition has an in order to furnish support for a spine weak-
overall prevalence in the UK of around 06 per ened by disease, after removal of the damaged
cent. bone. Also, the bone of young animals is used
to afford additional growth and strength to a
Causes The cardinal feature of gout is the limb-bone which it has been necessary to
presence of an excessive amount of uric acid in remove in part on account of disease or injury.
PLASMA and various body tissues, and its Research is also underway on artifical bone.
deposition in the joints in the form of sodium Vein grafts are used to replace stretches of arter-
monourate. The cause of this excess is not ies which have become blocked, particularly in
known, but there is an hereditary element and the heart and lower limbs. The veins most
there is a family history of the disease in 5080 commonly used for this purpose are the
per cent of cases. Inadequate exercise, habitual saphenous veins of the individual in question,
over-indulgence in animal food and rich dishes, provided they are healthy. An alternative is spe-
and excess of alcohol have been indicated as cially treated umbilical vein. (See SKIN-
precipitating factors, but the disease can occur GRAFTING.)
in vegetarians and teetotallers. When a replacement organ, such as kidney,
Gout is infrequent before the age of 40, but heart or liver, is grafted into someones body, it
it may occasionally affect very young people in called a transplant (see TRANSPLANTATION).
whom there is a strong family history. About 95
per cent of patients are males. In women it most Graft Versus Host Disease
often appears during the menopause. (GVHD)
A condition that is a common complication of
Symptoms An attack of gout may appear BONE MARROW transplant (see TRANSPLANTA-
without warning, or there may be premonitory TION). It results from certain LYMPHOCYTES in
symptoms. The affected joint is swollen and the the transplanted marrow attacking the trans-
symptoms come and go, usually being worse at plant recipients tissues, which they identify as
night. Tophi (see TOPHUS) may develop around foreign. GVHD may appear soon after a
an affected joint. Urinary CALCULI (urate- transplant or develop several months later. The
based) often occur in patients with gout. condition, which is fatal in about a third of
victims, may be prevented by immunosuppres-
Treatment and prevention NON- sant drugs such as ciclosporin.
STEROIDAL ANTI-INFLAMMATORY DRUGS
(NSAIDS) such as NAPROXEN should be started as Gram
soon as possible for an acute attack. After the The unit of weight in the metric system,
attack subsides, a lower dose should be con- equal to a little over 154 grains. For the pur-
tinued for at least a week. Salicylates (such as poses of weighing food, 30 grams are usually
aspirin) and diuretics should be avoided. taken as being approximately equal to an
 Grommet 305

ounce. (See APPENDIX 6: MEASUREMENTS IN forms of chronic inflammation, such as SYPH-

MEDICINE.) ILIS and TUBERCULOSIS.

Gram-Positive/Negative Gravel
See GRAMS STAIN. The name applied to any sediment which pre-
cipitates in the urine, but particularly to small
Grams Stain crystal masses of uric acid. It produces DYSURIA
Bacteria can be stained with an iodine-based and other urinary symptoms. (See URINARY
chemical dye called Grams stain (after the BLADDER, DISEASES OF; GOUT; URINE.)
scientist who discovered the technique). Dif-
ferent bacteria react differently to exposure to Graves Disease
the stain. Broadly, the bacterial specimens See THYROID GLAND, DISEASES OF.
are stained first with gentian violet, then
with Grams stain, and finally counterstained Gravid
with a red dye after a decolorising process. Bac- Pregnant (see PREGNANCY AND LABOUR). G
teria that retain the gentian stain are called
gram-positive; those that lose it but absorb the Greenstick Fracture
red stain are called gram-negative. Some species An incomplete fracture, in which the bone is
of staphylococcus, streptococcus and clostrid- not completely broken across. It occurs in the
ium are gram-positive, whereas salmonella and long bones of children and is usually due to
Vibrio cholerae are gram-negative. indirect force. (See BONE, DISORDERS OF Bone
fractures.)
Grand Mal
An out-of-date and now colloquial name for a Grey Matter
tonic-clonic seizure (in contrast to petit mal) Those parts of the BRAIN and SPINAL CORD that
see EPILEPSY.
comprise mainly the interconnected and tightly
packed nuclei of neurons (nerve cells). The tis-
sue is darker than that of the white matter,
Granisetron which is made of axons from the nerve cells. In
One of several serotonin antagonists used to the brain, grey matter is mainly found in the
treat nausea and vomiting induced by CYTO- outer layers of the cerebrum, which is the zone
TOXIC chemotherapy.
responsible for advanced mental functions. The
inner core of the spinal cord is made up of grey
Granulations matter.
Small masses of formative cells containing loops
of newly formed blood vessels which spring up Griseofulvin
over any raw surface, as the first step in the An antibiotic obtained from Penicillium griseo-
process of healing of wounds. (See ULCER; fulvum Dierckse, used to treat various forms of
WOUNDS.) RINGWORM.

Granulocytes Groin
A variety of white blood cells, also called poly- The region which includes the upper part of the
morphonuclear LEUCOCYTES, which, when front of the thigh and lower part of the abdo-
stained with Romanowsky stains containing men. A deep groove runs obliquely across it,
thiazine dyes and eosin, are found to contain which corresponds to the inguinal ligament,
granules in their cytoplasm. The colour of the and divides the thigh from the abdomen. The
granules enables the cells to be further classified principal diseased conditions in this region are
as basophils, eosinophils, and neutrophils. enlarged glands (see GLAND), and HERNIA.
Neutrophils isolate and destroy invading bac-
teria pus comprises mostly neutrophils. Grommet
Eosinophils are also involved in the bodys A small bobbin-shaped tube used to keep open
allergic response to foreign proteins, and baso- the incision made in the ear drum in the treat-
phils are involved in inflammatory and allergic ment of secretory otitis media. It acts as a venti-
reactions. lation tube by allowing the Eustachian tube to
recover its normal function. The operation is
Granuloma now less commonly performed than 20 years
A non-malignant or new growth made up of ago. (See EAR, DISEASES OF; EUSTACHIAN
granulation tissue. This is caused by various TUBES.)
 306 Group Therapy

Group Therapy ficially ventilated. Despite this, recovery is the

Psychotherapy in which at least two, but more rule.
commonly up to ten, patients, as well as the
therapist, take part. The therapist encourages Guinea-Worm
the patients to analyse their own and the others See DRACONTIASIS.
emotional and psychological difficulties. Group
therapy is also used to help patients sharing the Gulf War Syndrome
same condition for instance, alcoholism or A collection of varying symptoms, such as per-
compulsive gambling. They discuss their prob- sistent tiredness, headaches, muscle pain and
lems for perhaps an hour twice a week and poor concentration, reported by members of
explore ways of resolving them. the Coalition Armed Forces who served in the
1991 Gulf War. Whilst there is strong evidence
Growing Pains for a health effect related to service, there is no
Ill-defined discomfort and pains that occur in evidence of a particular set of signs and symp-
G the limbs of some children. They occur mainly toms (the definition of a syndrome) unique to
at night between the ages of 612 years. The those who served in the Gulf War. Symptoms
cause is unknown, but the condition is not sig- have been blamed on multiple possible hazards,
nificant and does not require treatment once such as exposure to depleted uranium muni-
other more important conditions have been tions, smoke from oil-well fires and use of pesti-
ruled out. cides. However, the only clearly demonstrated
association is with the particular pattern of vac-
cinations used to protect against biological
Growth weapons. Many conflicts in the past have gen-
A popular term applied to any new formation erated their own syndromes, given names such
in any part of the body. (See CANCER; CYSTS; as effort syndrome and shell-shock, suggesting a
GANGLION; TUMOUR.) For growth of children,
link to the psychological stress of being in the
see WEIGHT AND HEIGHT.
midst of warfare.
Growth Hormone Gullet
A product of the anterior part of the PITUITARY Gullet, or OESOPHAGUS, is the tube down
GLAND that promotes normal growth and which food passes from the throat to the
development in the body by changing the stomach.
chemical activity in the cells. The hormone
activates protein production in the muscle cells Gum
as well as the release of energy from the metab- (a) The soft tissue surrounding the TEETH. Also
olism of fats. Its release is controlled by the con- called the gingiva, this tissue protects under-
trasting actions of growth-hormone releasing lying structures and helps to keep the teeth
factor and somatostatin. If the body produces tightly in the jawbones. Inflammation of the
too much growth hormone before puberty gum is called gingivitis and may be due to den-
GIGANTISM results; in adulthood the result is tal PLAQUE or to systemic disorders such as
ACROMEGALY. Lack of growth hormone in chil- LEUKAEMIA and SCURVY.
dren retards growth. (b) A complex viscid substance which exudes
For many years growth hormone was from the stems and branches of various trees,
extracted from human corpses and very rarely and consists principally of arabin or bassorin.
this caused CREUTZFELDT-JAKOB DISEASE (CJD) The two best-known gums are gum acacia and
in the recipients. The hormone is now genetic- gum tragacanth. Gum-resins such as asafoetida,
ally engineered, so safe. galbanum and myrrh also contain resin.

Guillain-Barr Syndrome Gumboil

A disease of the peripheral nerves causing A painful condition of inflammation, ending
weakness and numbness in the limbs. It cus- sometimes as an ABSCESS, situated in the gum
tomarily occurs up to three weeks after an infec- about the root of a carious tooth (see TEETH,
tion for example, CAMPYLOBACTER infection DISORDERS OF Caries of the teeth).
of the gastrointestinal tract provoking an aller-
gic response in the nerves. It may begin with Gumma
weakness of the legs and gradually spread up the A hard swelling, or GRANULOMA, characteristic
body. In the worst cases the patient may of tertiary SYPHILIS. It normally develops in the
become totally paralysed and require to be arti- skin or subcutaneous tissue, mucous mem-
 Gyrus 307

branes or submucosa, and the long bones. fertilisation or IVF (see under ASSISTED CONCEP-
Although often painless, it may produce TION). Covering the full age range, it is closely
marked symptoms by interfering with the brain related to OBSTETRICS, while involving aspects
or other internal organs in which it may be of both surgery and psychiatry.
located. Treatment with penicillin (or tetra-
cycline if the patient is allergic) usually ensures Gynaecomastia
a rapid disappearance of the gumma. An abnormal increase in size of the male breast.

Gums, Diseases of Gypsum

See MOUTH, DISEASES OF; TEETH, DISEASES OF. Plaster of Paris used to stabilise and externally
splint fractured bones. It is applied wet and
GVHD moulded to the appropriate shape to immobil-
See GRAFT VERSUS HOST DISEASE (GVHD). ise the broken bone (see BONE, DISORDERS OF
Bone fractures.)
Gynaecology G
The branch of medicine dealing with the female Gyrus
pelvic and urogenital organs, in both the nor- Gyrus is the term applied to a convolution of
mal and diseased states. It encompasses aspects the BRAIN.
of CONTRACEPTION, ABORTION, and in vitro
 Haemarthrosis

H Haemarthrosis is the process of bleeding into,

or the presence of blood in, a joint. It may
occur as a result of major trauma (for example,
fracture of the patella may lead to bleeding into
the knee-joint), or, more commonly, following
minor trauma. It may even occur spon-
H2 Receptor Antagonists taneously, in cases of HAEMOPHILIA or other
These are drugs that block the action of HIS- disorders of blood clotting. If repeated several
TAMINE at the H2 receptor (which mediates the times, haemarthrosis may lead to FIBROSIS of the
gastric and some of the cardiovascular effects of joint-lining and inflammation of the cartilage,
histamine). By reducing the production of acid causing marked stiffness and deformity.
by the stomach, these drugs chiefly cimeti-
dine, ranitidine, famotidine and nizatidine Haematemesis
are valuable in the treatment of peptic ulcers Haematemesis means the vomiting of blood.
(healing when used in high dose; preventing Blood brought up from the stomach is generally
relapse when used as maintenance therapy in dark in colour and may have been so far
reduced dose), reflux oesophagitis (see OESOPH- digested as to form small brown granules
AGUS, DISEASES OF), and the ZOLLINGER- resembling coffee grounds. Vomiting of
ELLISON SYNDROME. These drugs are now blood is one of the main symptoms of PEPTIC
being supplanted by PROTON-PUMP INHIBITORS ULCER, but it may occur in GASTRITIS, from
and HELICOBACTER PYLORI eradication therapy. VARICOCOELES in the OESOPHAGUS, or, rarely,
(See also DUODENAL ULCER.) in cancer of the stomach. Gastritis caused by
an irritant poison, sustained intake of
Habit ALCOHOL, or the regular use of certain drugs
A behavioural response or practice that is estab- such as ASPIRIN and NON-STEROIDAL ANTI-
lished by the individual frequently repeating the INFLAMMATORY DRUGS (NSAIDS) may cause
same act. The process is called habituation, and bleeding. Blood may also originate from the
the more a person is exposed to a particular nose and throat, be swallowed and then
stimulus, the less is he or she aroused by it. vomited. Persistent haematemesis or a sudden
People may also become habituated to certain severe bleed is a potentially serious medical
drugs, requiring more and more of a substance emergency and the patient should be referred
to produce the same effect a process known as urgently to hospital (see HAEMORRHAGE).
TOLERANCE.
Haematinic
Habituation A drug that raises the quantity of HAEMO-
See HABIT. GLOBIN in the blood. Ferrous sulphate is a
common example of iron-containing com-
Haem pounds given to anaemic (see ANAEMIA) patients
An iron-containing porphyrin (see PORPHYRINS) whose condition is due to iron deficiency. Trad-
compound that combines with the protein itionally, haematinics have been used to prevent
GLOBULIN to make HAEMOGLOBIN, a constitu- anaemia in pregnant women, but nowadays a
ent of erythrocytes (red blood cells). maternal diet containing iron-rich foods and
regular antenatal checks of haemoglobin con-
Haemangioma centrations in the blood should make the rou-
These can be acquired or congenital. The tine use of haematinics unnecessary.
acquired type presents as a red PAPULE which
bleeds easily; treatment is normally by cautery. Haematocoele
A strawberry NAEVUS is a capillary- A cavity containing blood. Generally as the
cavernous haemangioma appearing at or soon result of an injury which ruptures blood vessels,
after birth, which may grow to a large size. blood is effused into one of the natural cavities
Treatment is not usually required, as most of of the body, or among loose cellular tissue, pro-
them fade although this may take a few ducing a haematocoele.
years. Where a haemangioma is disfiguring or
interfering with vision or breathing, treatment Haematocolpos
is necessary: this may be by laser, by using The condition in which menstrual blood can-
CORTICOSTEROIDS or INTERFERON treatment, not drain from the VAGINA because of an
or by surgery. imperforate HYMEN.
 Haemoglobin 309

Haematocrit Haemochromatosis
Also known as packed cell volume, this is an A disease in which cirrhosis of the liver (see
expression of the fraction of blood volume LIVER, DISEASES OF), enlargement of the
occupied by the ERYTHROCYTES. It is deter- SPLEEN, pigmentation of the skin, and DIA-
mined by centrifuging a sample of blood in a BETES MELLITUS are associated with the
capillary tube and measuring the height of the abnormal and excessive deposit in the organs of
resulting packed cells as a percentage of the the body of the iron-containing pigment,
total sample height. haemosiderin. It is caused by an increase in the
Normal values: amount of iron absorbed from the gastrointest-
males 4253 per cent or 0.420.53 mL/dL inal tract.
females 3248 per cent or 0.360.48 mL/dL
Haemodialysis
Haematogenous A method of removing waste products or
An adjective applied to a biological process poisons from the circulating blood using the
which produces blood, or to an agent produced principle of DIALYSIS. The procedure is used
in or coming from blood. For example, a on patients with malfunctioning or non-
haematogenous infection is one resulting from functioning KIDNEYS. It is done using an arti- H
contact with blood that contains a virus or bac- ficial kidney or dialyser which restores blood to
terium responsible for the infection. its normal state. The process has to be repeated,
sometimes for many months, until a donor
Haematologist kidney is available for transplantation to replace
A doctor or scientist who specialises in the study the patients failing one.
and treatment of blood and blood disorders.
Haemofiltration
Haematology A technique similar to HAEMODIALYSIS. Blood
The study of diseases of the blood. is dialysed using ultrafiltration through a mem-
brane permeable to water and small molecules
Haematoma (molecular weight <12,000). Physiological
Haematoma means a collection of blood form- saline solution is simultaneously reinfused.
ing a definite swelling. It is found often upon
the head of newborn children after a protracted Haemoglobin
and difficult labour (cephalhaematoma). It may The colouring compound which produces the
occur as the result of any injury or operation. red colour of blood. Haemoglobin is a chromo-
protein, made up of a protein called globin and
Haematuria the iron-containing pigment, haemin. When
Blood in the URINE. The blood may come from separated from the red blood corpuscles each
any part of the urinary tract. When the blood of which contains about 600 million haemo-
comes from the kidney or upper part of the globin molecules it is crystalline in form.
urinary tract, it is usually mixed throughout the Haemoglobin exists in two forms: simple
urine, giving the latter a brownish or smoky haemoglobin, found in venous blood; and oxy-
tinge. This condition is usually the result of haemoglobin, which is a loose compound with
glomerulonephritis, or it may be present in oxygen, found in arterial blood after the blood
persons suffering from high blood pressure or has come into contact with the air in the lungs.
PYELITIS. Blood may also appear in the urine This oxyhaemoglobin is again broken down as
when a stone or gravel is present in the pelvis of the blood passes through the tissues, which take
the kidney setting up irritation, especially after up the oxygen for their own use. This is the
exercise. The blood may also originate from a main function of haemoglobin: to act as a car-
bladder that is inflamed or infected or which rier of oxygen from the lungs to all the tissues of
contains benign growths (papilloma) or malig- the body. When the haemoglobin leaves the
nant growths. Inflammation or injury to the lungs, it is 97 per cent saturated with oxygen;
URETHRA can also cause haematuria. Someone when it comes back to the lungs in the venous
with haematuria should seek medical advice. blood, it is 70 per cent saturated. The oxygen
(See also KIDNEYS, DISEASES OF.) content of 100 millilitres of blood leaving the
lungs is 195 millilitres, and that of venous
Haemic Murmur blood returning to the lungs, 145 millilitres.
Unusual sounds heard over the heart and large Thus, each 100 millilitres of blood delivers 5
blood vessels in severe cases of ANAEMIA. They millilitres of oxygen to the tissues of the body.
disappear as the condition improves. Human male blood contains 1318 grams of
 310 Haemoglobinopathies

haemoglobin per 100 millilitres; in women, is due to blood-group incompatibility between

there are 1216 grams per 100 millilitres. A the mother and baby, the commoneset being
man weighing 70 kilograms (154 pounds) has rhesus incompatibility (see BLOOD GROUPS). In
around 770 grams of haemoglobin circulating this condition a rhesus-negative mother has
in his red blood corpuscles. been previously sensitised to produce rhesus
antibodies, either by the delivery of a rhesus-
Haemoglobinopathies positive baby, a miscarriage or a mismatched
Abnormal HAEMOGLOBIN formation occurs in blood transfusion. These antibodies cross over
the haemoglobinopathies, which are hereditary into the fetal circulation and attack red blood
haemolytic anaemias, genetically determined cells which cause HAEMOLYSIS.
and related to race. The haemoglobin may be
abnormal because: (1) there is a defect in the Treatment In severely affected fetuses, a fetal
synthesis of normal adult haemoglobin as in blood transfusion may be required and/or the
THALASSAEMIA, when there may be an absence baby may be delivered early for further treat-
of one or both of the polypeptide chains charac- ment. Mild cases may need observation only, or
teristic of normal adult haemoglobin; or (2) the reduction of jaundice by phototherapy
H there is an abnormal form of haemoglobin such alone (treatment with light, involving the use of
as haemoglobin S which results in sickle-cell sunlight, non-visible ULTRAVIOLET light, visible
disease (see ANAEMIA). This abnormality may blue light, or LASER).
involve as little as one amino acid of the 300 in Whatever the case, the infants serum BILI-
the haemoglobin molecule. In sickle-cell haemo- RUBIN the bilirubin present in the blood
globin, one single amino-acid molecule that of and its HAEMOGLOBIN concentration are plot-
glutamic acid is replaced by another that of ted regularly so that treatment can be given
valine; this results in such a deficient end product before levels likely to cause brain damage occur.
that the ensuing disease is frequently severe. Safe bilirubin concentrations depend on the
maturity and age of the baby, so reference charts
Haemoglobinuria are used.
The presence of blood pigment in the URINE High bilirubin concentrations may be
caused by the destruction of blood corpuscles in treated with phototherapy; extra fluid is given
the blood vessels or in the urinary passages. It to prevent dehydration and to improve bili-
turns urine a dark red or brown colour. In some rubin excretion by shortening the gut transit
people this condition, known as intermittent time. Severe jaundice and anaemia may require
haemoglobinuria, occurs from time to time, exchange TRANSFUSION by removing the babys
especially on exposure to cold. It is also pro- blood (usually 10 millilitres at a time) and
duced by various poisonous substances taken replacing it with rhesus-negative fresh bank
in the food. It occurs in malarious districts in blood. Haemolytic disease of the newborn sec-
the form of one of the most fatal forms of ondary to rhesus incompatibility has become
MALARIA: BLACKWATER FEVER. (See also MARCH less common since the introduction of anti-D
HAEMOGLOBINURIA.) (Rho) immunoglobulin. This antibody should
be given to all rhesus-negative women at any
Haemolysis risk of a fetomaternal transfusion, to prevent
The destruction of red blood corpuscles by the them from mounting an antibody response.
action of poisonous substances, usually of a Anti-D is given routinely to rhesus-negative
protein nature, circulating in the blood, or by mothers after the birth of a rhesus-positive
certain chemicals. It occurs, for example, grad- baby, but doctors should also give it after
ually in some forms of ANAEMIA and rapidly in threatened abortions, antepartum haemor-
poisoning by snake venom. rhages, miscarriages, and terminations of
pregnancy.
Haemolytic Disease of the Occasionally haemolytic disease is caused by
Newborn ABO incompatibility or that of rarer blood
A potentially serious disease of the newborn, groups.
characterised by haemolytic ANAEMIA (excessive
destruction of red blood cells) and JAUNDICE. If Haemolytic Uraemic Syndrome
severe, it may be obvious before birth because A disease of children resulting in acute RENAL
the baby becomes very oedematous (see failure. A febrile illness of the gastrointestinal or
OEDEMA) and develops heart failure so-called respiratory tracts is followed by intravascular
hydrops fetalis. It may first present on the first COAGULATION of blood which results in
day of life as jaundice and anaemia. The disease HAEMOLYSIS, ANAEMIA, THROMBOCYTOPAENIA
 Haemoptysis 311

and renal failure (resulting from fibrin VIII levels to 30100 per cent by giving
deposition in renal arterioles and glomerular cryoprecipitate.
capillaries). With treatment, most haemophiliacs lead
The death rate is 210 per cent and the normal lives, although obviously dangerous or
majority of patients survive without renal fail- contact sports should be avoided. Before donors
ure. The longer the period of OLIGURIA, the of blood were screened for HEPATITIS B and C
greater the risk of chronic renal failure. or for HIV infection (see AIDS/HIV), some indi-
Treatment is supportive, with replacement of viduals with haemophilia receiving factor VIII
blood and clotting factors, control of HYPERTEN- were unwittingly infected with those diseases.
SION, and careful observation of fluid balance. Todays screening procedures make such infec-
tions very unlikely.
Haemopericardium There is a National Haemophilia Register
The presence of blood in the PERICARDIUM, the and each registered sufferer carries a card with
membranous sac which surrounds the heart. details about his or her condition. Information
The condition may result from a myocardial may also be obtained from NHS haemophilia
infarction (see HEART, DISEASES OF), leaking centres and the Haemophilia Society.
ANEURYSM, injury, or tumour. Because the peri-
H
cardial blood compresses the heart, the latters Haemophilus
pumping action is impeded, reducing the blood Gram-negative (see GRAMS STAIN), rod-like,
pressure and causing cardiac failure. Urgent aerobic, non-sporing and non-motile parasitic
surgical drainage of the blood may be required. bacteria. Mostly found in the respiratory tract,
they may be part of the normal flora, but may
Haemophilia also be responsible for several diseases. The
An inherited disorder of blood COAGULATION main pathogenic species of haemophilus is H.
which results in prolonged bleeding even after influenzae, which may cause severe exacerba-
minor injury. There is a deficiency of factor tions of chronic BRONCHITIS, as well as MEN-
VIII, an essential clotting factor in the coagula- INGITIS, EPIGLOTTITIS, SINUSITIS, and otitis
tion cascade the complex series of bio- media (see EAR, DISEASES OF). Other species may
chemical events that leads from injury of the cause conjunctivitis (see EYE, DISORDERS OF) or
wall of a blood vessel to the formation of a CHANCROID. Haemophilus species are sensitive
blood clot that checks bleeding. Haemophilia is to a wide range of antibiotics, though generally
a sex-linked recessive disorder (though a small resistant to penicillin. Infants are routinely
number of cases arise by spontaneous muta- immunised with Haemophilus B vaccine to
tion), so that, if females carry the disease, one- prevent meningitis, septicaemia and epiglottitis
half of their sons will be affected and one-half of all potentially fatal disesases.
their daughters will be carriers. The sons of
haemophiliacs are unaffected but one-half of Haemopoietic Stem Cell
their daughters will be carriers. This is the basic cell from which all types of
Haemophilia affects approximately 1:4,000 blood cells originate. Its appearance is believed
of the UK population but only 1:20,000 is to be similar to that of a LYMPHOCYTE.
severely affected. Severity of the disease depends
upon the percentage, compared with normal, of Haemopoiesis
factor VIII activity present. Less than 1 per cent The formation of blood cells and PLATELETS a
and there will be spontaneous bleeding into continuous process throughout life. As ageing
joints and muscles; 15 per cent and there will cells are removed from the circulation, new
be occasional spontaneous bleeding and severe ones, generated in the BONE MARROW, replace
bleeding after minor injury; 525 per cent and them.
there will only be severe bleeding after major
injury. Before treatment was available, severe Haemoptysis
haemophiliacs suffered from acute pain and The coughing-up of blood from the lungs. The
deformity from bleeds into joints and muscles. blood is usually bright red and frothy, thus dis-
Bleeding also occurred into the gut, kidneys and tinguishing it from blood brought up from the
brain, and few survived past adolescence. stomach. It is a potentially serious sign of lung
Freeze-dried factor VIII may be kept in disease, although in elderly people haemoptysis
domestic refrigerators. Haemophiliacs can use may be due to a varicose condition of the small
it to abort minor bleeds by reconstituting it and veins in the throat. In young people this condi-
injecting it intravenously. More major bleeding tion is often due to bleeding from the nose, in
or preparation for surgery involves raising factor which, owing to the position of the head, the
 312 Haemorrhage

blood happens to run backwards instead of veins in the lining of the ANUS. They are very
forwards through the nostrils. (See also HAEM- common, affecting nearly half of the UK popu-
ORRHAGE; TUBERCULOSIS.) lation at some time in their lives, with men
having them more often and for a longer time.
Haemorrhage
The escape of blood from any of the blood ves- Varieties Haemorrhoids are classified into
sels, normally in response to some trauma, or as first-, second- and third-degree, depending on
a result of a clotting disorder such as HAEMO- how far they prolapse through the anal canal.
PHILIA. The bleeding may be external for First-degree ones do not protrude; second-
example, following a skin laceration; or it may degree piles protrude during defaecation;
be internal for example, haematemesis (bleed- third-degree ones are trapped outside the anal
ing into the stomach), haemoptysis (bleeding margin, although they can be pushed back.
from the lungs), or haematuria (bleeding from Most haemorrhoids can be described as
the kidneys or urinary tract). For more informa- internal, since they are covered with glandular
tion about these conditions, see separate entries. mucosa, but some large, long-term ones develop
Bleeding into or around the brain is a major a covering of skin. Piles are usually found at the
H concern following serious head injuries, or in three, seven and eleven oclock sites when
newborn infants following a difficult labour. viewed with the patient on his or her back.
Haemorrhage is classified as arterial the most
serious type, in which the blood is bright red and Causes The veins in the anus tend to become
appears in spurts (in severe cases the patient may distended because they have no valves; because
bleed to death within a few minutes); venous they form the lowest part of the PORTAL SYSTEM
less serious (unless from torn varicose veins) and and are apt to become overfilled when there is
easily checked, in which the blood is dark and the least interference with the circulation
wells up gradually into the wound; and capillary, through the portal vein; and partly because the
in which the blood slowly oozes out of the sur- muscular arrangements for keeping the rectum
face of the wound and soon stops spontaneously. closed interfere with the circulation through the
Haemorrhage is also classified as primary, haemorrhoidal veins. An absence of fibre from
reactionary, and secondary (see WOUNDS). Severe western diets is probably the most important
haemorrhage causes SHOCK and ANAEMIA, and cause. The result is that people often strain to
blood TRANSFUSION is often required. defaecate hard stools, thus raising intra-
When a small artery is cut across, the bleed- abdominal pressure which slows the rate of
ing stops in consequence of changes in the wall venous return and engorges the network of
of the artery on the one hand, and in the consti- veins in the anal mucosa. Pregnancy is an
tution of the blood on the other. Every artery is important contributory factor in women devel-
surrounded by a fibrous sheath, and when cut, oping haemorrhoids. In some people, haemor-
the vessel retracts some little distance within rhoids are a symptom of disease higher up in
this sheath and a blood clot forms, blocking the the portal system, causing interference with the
open end (see COAGULATION). When a major circulation. They are common in heart disease,
blood vessel is torn, such spontaneous closure liver complaints such as cirrhosis or congestion,
may be impossible and surgery is required to and any disease affecting the bowels.
stop the bleeding.
Three main principles are applicable in the Symptoms Piles cause itching, pain and often
control of a severe external haemorrhage: (a) bleeding, which may occur whenever the
direct pressure on the bleeding point or points; patient defaecates or only sometimes. The piles
(b) elevation of the wounded part; (c) pressure may prolapse permanently or intermittently.
on the main artery of supply to the part. The patient may complain of aching discomfort
Control of internal haemorrhage is more dif- which, with the pain, may be worsened.
ficult than that of external bleeding. First-aid
measures should be taken while professional Treatment Prevention is important; a high-
help is sought. The patient should be laid down fibre diet will help in this, and is also necessary
with legs raised, and he or she should be after piles have developed. Patients should not
reassured and kept warm. The mouth may be spend a long time straining on the lavatory.
kept moist but no fluids should be given. (See Itching can be lessened if the PERINEUM is
APPENDIX 1: BASIC FIRST AID.) properly washed, dried and powdered. Pro-
lapsed piles can be replaced with the finger.
Haemorrhoids Local anaesthetic and steroid ointments can
Haemorrhoids, or piles, are varicose (swollen) help to relieve symptoms when they are rela-
 Hallux Rigidus 313

tively mild, but do not remedy the underlying Halibut-Liver Oil

disorder. If conservative measures fail, then sur- The oil expressed from fresh, or suitably pre-
gery may be required. Piles may be injected, served, halibut liver. It is a particularly rich
stretched or excised according to the patients source of vitamin A (30,000 international units
particular circumstances. per gram), and also contains vitamin D (2,300
Where haemorrhoids are secondary to 2,500 units per gram). It is available in capsules
another disorder, such as cancer of the rectum as a means of providing the two vitamins. (See
or colon, the underlying condition must be APPENDIX 5: VITAMINS.)
treated hence the importance of medical
advice if piles persist. Halitosis
Bad breath. This may be a sign of illness for
Haemosiderosis example, lung disease or SINUSITIS; and a per-
An increase in the amount of iron stored in the son with DIABETES MELLITUS may have breath
body. Rarely, it may be due to ingestion of too tainted with acetone if his or her sugar metabol-
much iron, but a more likely cause is repeated ism is poorly controlled. Usually, however, hali-
blood transfusions. The extra iron may affect tosis is caused by smoking, drinking alcohol,
the function of the heart and liver. eating certain foods (garlic or onions), or H
inadequate oral and dental hygiene.
Haemostasis
The process by which bleeding stops. It involves Hallucinations
constriction of blood vessels, the formation of a False perceptions arising without an adequate
platelet plug, and blood clotting. The term is external stimulus, as opposed to illusions,
also used for surgical interventions to stop which are misinterpretations of stimuli arising
bleeding for example, the use of diathermy. from an external object. Hallucinations come
(See COAGULATION; HAEMORRHAGE.) from within, although the affected individual
may see them as coming from without. Never-
Haemostatics theless, they may occur at the same time as real
A group of drugs used to treat bleeding dis- perceptions, and may affect any sense (vision,
orders such as HAEMOPHILIA. Factor VIII is one hearing, smell, taste, touch, etc.).
of the clotting factors available for treatment:
preparations of it are injected after abnormal Causes They may be the result of intense
bleeding or before surgery. Vitamin K prepar- emotion or suggestion, sensory deprivation (for
ations are another haemostatic group used to example, overwork or lack of sleep), disorders of
treat an overdose of ANTICOAGULANTS. sense organs, or disorders of the central nervous
Haemostatic preparations of gelatine and cel- system. Although hallucinations may occur in
lulose are used to stem bleeding from the skin perfectly sane people, they are more commonly
and gums, or as a result of tooth extractions. an indication of a MENTAL ILLNESS. They may
be deliberately induced by the use of
Haemothorax HALLUCINOGENS.
An effusion of blood into the PLEURAL CAVITY.
Hallucinogens
Hair, Removal of Compounds characterised by their ability to
See DEPILATION. produce distortions of perception, emotional
changes, depersonalisation, and a variety of
Hair effects on memory and learned behaviour. They
See SKIN; WHITE HAIR. include CANNABIS, LYSERGIC ACID DIETHYL-
AMIDE (LSD) and MESCALINE. (See also
Half Life DEPENDENCE.)
The time taken for the PLASMA concentration of
an administered drug to decline by half as a Hallux
result of redistribution, METABOLISM and The anatomical name of the great toe.
EXCRETION.
Hallux Rigidus
Halfway House Stiffness of the joint between the great toe and
A residential home for mentally ill individuals the foot, which induces pain on walking. It is
where they can live under supervision after dis- usually due to a crush injury or stubbing of the
charge from hospital. They may be fit to work toe. Such stubbing is liable to occur in adoles-
but cannot manage an independent life. cents with a congenitally long toe. If trouble-
 314 Hallux Valgus

some, the condition is treated by an operation tissue such as smooth muscle and connective
to create a false joint. tissue.

Hallux Valgus Hamate

Outward displacement of the great toe always One of the carpal bones of the HAND that
associated with a bunion (see CORNS AND BUN- articulate between the METATARSAL BONES and
IONS). It is due to the pressure of footwear on an the RADIUS and ulnar bones of the forearm.
unduly broad foot. In adolescents, this broad
foot is inherited; in adults it is due to splaying of Hammer-Toe
the foot as a result of loss of muscle tone. The The deformity in which there is permanent flex-
bunion is produced by pressure of the footwear ion, or bending, of the middle joint of the toe.
on the protruding base of the toe. In mild cases The condition may affect all the toes, as in
the wearing of comfortable shoes may be all that CLAW-FOOT; more commonly it affects one toe,
is needed. In more severe cases the bunion may usually the second. It is due to a relatively long
need to be removed, while in the most severe the toe and the pressure on it of the footwear. A
operation of ARTHROPLASTY may be needed. painful bunion usually develops on it (see
CORNS AND BUNIONS). In mild cases, relief is
H
Halo obtained by protecting the toe with adhesive
A coloured circle seen around a bright light in pads. If this does not suffice then an operation
some eye conditions. When accompanied by is necessary.
headache, it is especially likely to be caused by
GLAUCOMA. Hamstrings
The name given to the tendons at the back of
Haloperidol the knee two on the inner side and one on the
One of the butyrophenone group of drugs used outer side which bend this joint. They are
to treat patients with psychoses (see PSYCHOSIS). attached to the tibia below. Strains, or pulls,
Its action is similar to that of the PHENOTHI- and tears of the hamstring are common in
AZINES. It is also used in depot form, being people taking part in strenuous sports such as
administered by deep intramuscular injection athletics, football, rugby and tennis (see SPORTS
for maintenance control of SCHIZOPHRENIA MEDICINE).
and other psychoses. The drug may help to
control tics and intractable hiccups. Hand
In structure, the hand has a bony basis of eight
Halothane small carpal bones in the wrist, five metacarpal
A volatile liquid anaesthetic, used for many bones in the fleshy part of the hand, and three
years as a potent inhalant anaesthetic. It pro- phalanges in each finger two only in the
vides smooth induction of ANAESTHESIA and is thumb. From the muscles of the forearm, 12
non-irritant and pleasant to inhale. A few strong tendons run in front of the wrist. Of
patients have an idiosyncracy to halothane, these, nine go to the fingers and thumb and are
putting them at risk if it is used frequently, so a bound down by a strong band, the flexor reti-
careful history is essential before it is adminis- naculum, in front of the wrist. They are
tered to a patient (see HALOTHANE HEPATITIS). enclosed in a complicated synovial sheath, and
pass through the palm and down the fingers.
Halothane Hepatitis Behind the wrist, 12 tendons likewise cross
A very rare form of HEPATITIS following from forearm to hand.
exposure to HALOTHANE during anaesthesia Forming the ball of the thumb and that of
(1:35,000 halothane anaesthetics). Jaundice the little finger, and filling up the gaps between
develops three to four days after exposure and the metacarpal bones, are other muscles, which
will occasionally develop into a fatal massive act to separate and bring together the fingers,
hepatic necrosis. It is of unknown aetiology but and to bend them at their first joints (knuckles).
probably has an immunological basis. It is more
common following multiple exposures in a Hand, Foot and Mouth Disease
short time (less than 28 days), and in obesity, A contagious disease due to infection with cox-
middle age and females. It is rare in children. sackie A16 virus (see COXSACKIE VIRUSES).
Most common in children, the incubation
Hamartoma period is 35 days. It is characterised by an
These are benign tumours, usually in the lung, eruption of blisters on the palms and the feet
containing normal components of pulmonary (often the toes), and in the mouth. The disease
 Hapten 315

ensure that these are user-friendly to such indi-

viduals. The health and social-work professions
also contribute to reducing the impact of
handicaps on the affected individuals.

Hanging
Hanging is a form of death due to suspension of
the body from the neck either suddenly, as in
judicial hanging (although not in the United
Kingdom, as the death penalty is not used in the
UK justice system), so as to damage the spinal
column and cord, or in such a way as to constrict
the AIR PASSAGES and the blood vessels to the
brain. Death is, in any case, speedy, resulting in
23 minutes if not instantaneously. Apart from
judicial hanging, and in the absence of any signs
of a struggle, hanging is usually due to SUICIDE. H
The resuscitation of people found hanging is
similar to that for drowning. (See APPENDIX 1:
BASIC FIRST AID Cardiac/respiratory arrest.)

Hang-Nail
A splitting of the skin (cuticle) at the side of a
fingernail. In manual workers it is usually
caused by trauma, but ISCHAEMIA of the fingers
(see also RAYNAUDS DISEASE) may predispose to
the condition. Secondary infection and
inflammation may make hang-nail a very ten-
der condition; treatment consists of reducing
trauma, and the use of EMOLLIENTS and ANTI-
BIOTICS if necessary.

Hansens Disease
See LEPROSY.
The bones of the right hand and wrist (anterior
view). Bones marked (c) form the carpal group of
bones.
Hantavirus
A group of viruses that infect mice, rats and
voles and can also infect humans who come
has no connection with foot and mouth disease into contact with the excreta or secretions of
in cattle, deer, pigs and sheep. these animals. Widely distributed in Asia, the
USA and Europe, in Britain hantavirus usually
Handicap affects rural and sewage workers, as well as
The inability to carry out a social, occupational people engaged in watersports. Many victims
or other activity that could normally be done by have a mild feverish illness; severe cases are
a person without such a handicap. The handi- characterised by headache, high temperature,
cap may be partial or complete, physical or nausea, vomiting and even shock, accompanied
mental, and may result from disease, injury or by skin PETECHIAE. The kidneys and sometimes
inherited disorder. The extent of the handicap the lungs are affected, and in severely affected
is measured against the normal function of patients mortality is high.
those in a peer group. The impairment may be
functionally rather than physically based, in Haploid
which case the affected person may not always An adjective describing organisms, cells or
be aware of it until revealed by a clinical exam- nuclei that have a single set of unpaired CHRO-
ination. Considerable government and volun- MOSOMES. Human beings have haploid gam-
tary community efforts have been made to etes (see GAMETE) following MEIOSIS.
lessen the day-to-day difficulties of living faced
by disabled people. Increasingly, public build- Hapten
ings, houses and vehicles are being modified to See ANTIGEN.
 316 Hard Water

Hard Water The mainstays of treatment are ANTIHISTA-

The term applied to water that contains a large MINE DRUGS, taken by mouth, and the use of
amount of calcium and magnesium salts (lime steroid and cromoglycate nasal sprays and eye
salts). These form an insoluble curd with soap drops. Occasionally desensitisation by injection
and thus interfere with the use of the water for may work if the particular allergen is known.
washing. Hard water is especially found in dis-
tricts where the soil is chalky. Temporary hard- HDA
ness, which is due mainly to the presence of See HEALTH DEVELOPMENT AGENCY (HDA).
bicarbonates of lime, can be remedied by boiling,
when the lime is precipitated as carbonate of Head
lime. Permanent hardness is not remedied by See BRAIN; FACE; SCALP; SKULL.
boiling, and is due to the presence of a large
amount of sulphate of lime. It may be removed Headache
by the addition of sodium carbonate (washing A very common condition which may vary con-
soda) or by the Permutit process which involves siderably in severity, type, significance and
the use of various combinations of silicate of cause. At one extreme, headache may indicate
H alumina and soda. In the past, hard water was the presence of a tumour or MENINGITIS, while
often blamed for many ills without any con- at the other it may merely indicate a common
vincing evidence. Epidemiologists suggest that cold or tiredness. Even so, persistent or recur-
drinking soft water may lead to a greater risk of rent headaches should always be taken seriously.
heart disease. Although the brain itself is insensitive to pain,
the surrounding membranes meninges are
Hare-Lip very sensitive, and changes in intracranial arter-
See PALATE, MALFORMATIONS OF. ies, or spasm of the neck or scalp muscles,
which may occur for various reasons, may cause
Hartmanns Solution considerable pain. In most cases a clinical diag-
A solution commonly used as a means of fluid nosis should be possible; further investigations
replacement in dehydrated patients (see also should only be necessary following head injury,
DEHYDRATION). Each litre contains 31 grams if headaches recur, or if neurological signs such
of sodium lactate, 6 grams of sodium chloride, as drowsiness, vomiting, confusion, seizures or
04 grams of potassium chloride, and 07 grams focal signs develop.
of calcium chloride. Stress and anxiety are probably the most
common causes of headache and, where pos-
Hashimotos Disease sible, the reasons overwork, family problems,
A condition in which the whole of the THYROID
GLAND is diffusely enlarged and firm. It is one unemployment, financial difficulties, etc.
of the diseases produced by AUTOIMMUNITY. should be tackled. An unpleasant environment
The enlargement is due to diffuse infiltration of such as traffic pollution or badly ventilated or
lymphocytes and increase of fibrous tissue. overcrowded working conditions may provoke
This form of GOITRE appears in middle-aged headaches in some people, as may excessive
women, does not give rise to symptoms of thy- smoking or caffeine intake. MIGRAINE is a char-
rotoxicosis (see THYROID GLAND, DISEASES OF acteristic and often disabling type of headache;
Thyrotoxicosis), and tends to produce myx- high blood pressure may cause the condition
oedema (see THYROID GLAND, DISEASES OF (see HYPERTENSION); and, occasionally, refract-
Hypothyroidism). ive errors of the eyes (see EYE, DISORDERS OF) are
associated with headaches. SINUS infections are
Haversian Canals often characterised by frontal headaches.
The fine canals in BONE which carry the blood Rheumatism in the muscles of the neck and
vessels, lymphatics and nerves necessary for the scalp produce headaches; fever is commonly
maintenance and repair of bone. accompanied by a headache; and sunstroke and
HEAT STROKE customarily result in headaches.
Hay Fever Finally, diseases in the brain such as meningitis,
Also known as allergic rhinitis, this is caused by tumours and HAEMORRHAGE may first manifest
an ALLERGY to the pollen of grasses, trees and themselves as persistent or recurrent headaches.
other plants. Contact with the particular pollen
to which the sufferer is allergic causes HISTAMINE Treatment Obtaining a reliable diagnosis
release, resulting in a blocked, runny nose and with the help of further investigations, includ-
itchy, watering eyes. It affects approximately 3 ing CT (see COMPUTED TOMOGRAPHY) or MRI
million people each year in the UK. scanning when indicated should always be the
 Health-Care Priorities 317

initial aim; treatment in most cases should then freedom from disease, and good health may be
be aimed at the underlying condition. Particular defined as the attainment and maintenance of
concerns include headache that worsens at the highest state of mental and bodily vigour of
night or in the early morning; ever-increasing which any given individual is capable.
headaches; those associated with abnormal Environment, including living and working
neurological signs on examination; or those conditions, plays an important part in deter-
associated with fits (see FIT). mining a persons health. The UK government
Whether the cause is physical or stress- is now placing much greater emphasis on health
induced, used sensibly and for a limited period a promotion and the prevention of disease, and
low dose of aspirin or paracetamol may be help- has published national targets for reducing the
ful. In many cases of stress-induced headache, incidence of some major diseases. The 1978
however, the most effective treatment is relax- World Health Organisation statement declares
ation. There are many specific treatments for that primary care should be made universally
migraine and hypertension. Sinusitis is treated accessible to individuals and families in the
with antibiotics and sometimes by surgery. community, by means acceptable to them,
through their full participation, and at the cost
Head Injury that the community and country can afford to H
Any injury to the head, whether associated with maintain in the spirit of self-reliance . . . [and]
a skull fracture (see BONE, DISORDERS OF Bone addresses the main health problems in the
fractures) or not. Patients with head injuries community, providing promotive, preventa-
should be assessed for signs of neurological tive, curative and rehabilitative services accord-
damage, which may not develop at once. ingly. Factors affecting access to health
Patients who after a head injury are or have include finance, ideology, and education. (See
been UNCONSCIOUS or who are drowsy, vomit- ENVIRONMENT AND HEALTH; PUBLIC
ing, confused or have any focal neurological HEALTH.)
signs for example, blurred vision or a motor
or sensory malfunction should be seen by a Health and Safety Executive
doctor. Particular care should be taken with (HSE)
individuals who have consumed alcohol and The statutory body in Britain responsible for
sustained a head injury in a fight, fall or vehicle the health and safety of workers. The address of
accident. Symptoms indicative of a severe head the HSE can be found in APPENDIX 7: STATU-
injury may be attributed (wrongly) to the TORY ORGANISATIONS.
effects of alcohol, and crucial time thus lost in
treating the injury. Health-Care Priorities
In hospital the possible need for urgent As the needs and demands of patients, and the
action is monitored by use of the GLASGOW costs of health care of populations, have risen
COMA SCALE. sharply in recent years, governments and
People suffering the results of such injuries health-care providers whether tax-funded,
and their relatives can obtain help and advice insurance-based, employer-provided or a mix of
from Headway the brain injury association. these have had increasingly to face the
dilemma of what services a country or a
Heaf Test community can afford to provide. As a result,
A skin test to find out if a person is immune to various techniques for deciding priorities of
TUBERCULOSIS. TUBERCULIN (a preparation care and treatment are evolving. In the United
derived from the TUBERCLE bacillus) is injected Kingdom, priorities were for many years based
via punctures in the skin of the forearm, using a on the decisions of individual clinicians who
spring-loaded gunlike instrument with six very had wide freedom to prescribe the most
short needles set in circular form. A positive test appropriate care. Increasingly, this clinical free-
is indicated by a red raised reaction of the skin: dom is being circumscribed by managerial,
this means that the subject is immune. If the community and political decisions driven in
result is negative, the subject can be given BCG part by the availability of resources and by what
VACCINE. people want. Rationing services, however, is not
popular and as yet no broadly agreed consensus
Healing has emerged, either in western Europe or in
See WOUNDS. North America, as to how priorities can be
decided that have broad community support
Health and which can be afforded. (See CLINICAL GOV-
The state of health implies much more than ERNANCE; EVIDENCE-BASED MEDICINE.)
 318 Health Centre

Health Centre the HEALTH DEVELOPMENT AGENCY (HDA) (see

An imprecise term that may refer to a group of also APPENDIX 7: STATUTORY ORGANISATIONS).
doctors and supporting staff operating from one
building owned or leased by the doctors, or to a Health Impact Assessment
building owned or leased by a health authority This is a structured, multi-disciplinary process
that contains staff or services from one or more for assessing and improving the health con-
sections of the National Health Service. sequences of projects and policies in the non-
health sector. It combines a range of qualitative
Health Databases and quantitative evidence in preparing conclu-
The centralised collection and storage of infor- sions. Applications of the assessments include
mation about the health of individuals. Recent appraisal of national policies, local urban plan-
advances in GENETICS have raised concerns ning, and the progress of transport, water and
about the potential for abuse of all health data- agricultural projects.
bases, whether maintained for scientific
research which has long used them or for Health Promotion
government or community health planning, or A surveillance plan based on a community, and
H by groups of professionals (or individuals) to aimed at maintaining an optimum state of
help in the treatment of patients. The public is health and quality of life for those who make up
concerned about whether their rights to privacy the community both as individuals and as a
and confidentiality are threatened by databases group. Programmes would include immunisa-
and whether information about them could be tion targets, health education and screening
disclosed and misused. tests, as well as environmental procedures such
as monitoring atmosphere, improving housing,
Health Development Agency water and food supplies, and encouraging safe
(HDA) and healthy working practices. (See ENVIRON-
Appointed by the UK government to help MENT AND HEALTH; PUBLIC HEALTH.)
improve the NHS in England (Scotland, Wales
and Northern Ireland have similar bodies), Health Service Commissioner
HDA replaced the long-established Health An official, responsible to the United King-
Education Authority in April 2000. The agency doms parliament, appointed to protect the
supports government priorities to improve pub- interests of National Health Service patients in
lic health and to tackle health inequalities. matters concerning the administration of
Among its key functions are: the health service and the delivery of health
Maintaining an up-to-date evidence base of
what works in public health and health
care (excluding clinical judgements). Known
colloquially as the health ombudsman, the
improvements. Commissioner presents regular reports on the
Providing useful information to health
practitioners.
complaints dealt with.

Commissioning research to remedy the gaps Health-Service Management

in the evidence base for medical practice. The administrative machinery for planning,
Improving health promotion and advising
on the standards for (and implementation
delivering and monitoring health care provided
by health professionals and their supporting
of ) public-health activities. staff. This may range from running a small
(See APPENDIX 7: STATUTORY ORGANISATIONS.) primary-care centre to organising a large hos-
pital or being responsible for meeting the health
Health Education needs of a region or a nation. Whether the
The process of educating the public to adopt a overall structure for proving care is state-
healthy lifestyle and abandon dangerous or funded, insurance-based, private-practice or a
unhealthy behaviour. With the rising cost of mixture of these, health-service management is
health care and the increasing amount of illness essential in an era of rapidly evolving and
and injury resulting from preventable causes, expensive scientific medicine. Health-service
health professionals, governments and the managers are administrators with special train-
World Health Organisation are strongly sup- ing and skills in managing health care; some-
porting more and better health education for times they are doctors, nurses or other health
everyone from schoolchildren to the elderly. professionals, but many have been trained in
Information on all aspects of health education management in commercial, civil service or
in the United Kingdom can be obtained from industrial environments.
 Heart 319

Health Visitors aids are worn entirely within the ear and are
Health visitors are community nurses with a very discreet. They are particularly useful for
special training who form an important part of people who have to wear protective headgear
the primary health-care team. Working in close such as helmets.
conjunction with general practitioners, they are The most sophisticated aids sit entirely
primarily responsible for illness prevention and within the ear canal so are virtually invisible.
health screening and education of children and They may be tuned so that only the frequencies
elderly people in the community. the wearer cannot hear are amplified.
Many have a volume control and a special
Healthcare Commission setting for use with telephone and in rooms fit-
(Commission for Health ted with an inductive coupler that screens out
Improvement) background noise.
Launched in 1999 in England and Wales as In making a choice therefore from the large
CHI, this is an inspectorate charged with pro- range of effective hearing aids now available,
tecting patients from unacceptable failings in the expert advice of an ear specialist must be
the National Health Service. A statutory body obtained. The RNID (Royal National Institute
under the 1999 Health Act, it evaluates and for Deaf People) provides a list of clinics where H
refines local systems designed to safeguard such a specialist can be consulted. It also gives
standards of clinical quality. Working separately reliable advice concerning the purchase and use
from the NHS and the health departments, it of hearing aids a worthwhile function, as
offers an independent safeguard that provides some aids are very expensive.
systems to monitor and improve clinical quality
in primary care, community services and hos- Heart
pitals. As of 2004 it became responsible for A hollow muscular pump with four cavities,
dealing with patients complaints if they could each provided at its outlet with a valve, whose
not be settled by the trust concerned. The function is to maintain the circulation of the
board members include health professionals, blood. The two upper cavities are known as
academics and eight lay members. Scotland has atria; the two lower ones as ventricles. The term
set up a similar statutory body. (See APPENDIX 7: auricle is applied to the ear-shaped tip of the
STATUTORY ORGANISATIONS.) atrium on each side.

Hearing Shape and size In adults the heart is about

See DEAFNESS; EAR. the size and shape of a clenched fist. One end
of the heart is pointed (apex); the other is broad
Hearing Aids (base) and is deeply cleft at the division between
Nearly two-thirds of people aged over 70 have the two atria. One groove running down the
some degree of hearing impairment (see DEAF- front and up the back shows the division
NESS). Hearing aids are no substitute for defini- between the two ventricles; a circular, deeper
tive treatment of the underlying cause of poor groove marks off the atria above from the vent-
hearing, so examination by an ear, nose and ricles below. The capacity of each cavity is
throat surgeon and an audiologist is sensible somewhere between 90 and 180 millilitres.
before a hearing aid is issued (and is essential
before one can be given through the NHS). Structure The heart lies within a strong
The choice of aid depends on the age, manipu- fibrous bag, known as the pericardium. Since
lative skills, and degree of hearing impairment the inner surface of this bag and the outer sur-
of the patient and the underlying cause of the face of the heart are both covered with a
deafness. The choice of hearing aid for a deaf smooth, glistening membrane faced with flat
child is particularly important, as impaired cells and lubricated by a little serous fluid
hearing can hinder speech development. (around 20 ml), the movements of the heart are
Electronic aids consist, essentially, of a accomplished almost without friction. The
microphone, an amplifier, and an earphone. In main thickness of the heart wall consists of
postaural aids the microphone and amplifier are bundles of muscle fibres, some of which run in
contained in a small box worn behind the ear or circles right around the heart, and others in
attached to spectacles. The earphone is on a loops, first round one cavity, then round the
specially moulded earpiece. Some patients find corresponding cavity of the other side. Within
it difficult to manipulate the controls of an aid all the cavities is a smooth lining membrane,
worn behind the ear, and they may be better off continuous with that lining the vessels which
with a device worn on the body. Some hearing open into the heart. The investing smooth
 320 Heart, Artificial

membrane is known as epicardium; the muscu- heart sounds, and can be heard by anyone who
lar substance as myocardium; and the smooth applies his or her ear to the front of a persons
lining membrane as endocardium. chest. Murmurs heard accompanying these
Important nerves regulate the hearts action, sounds indicate defects in the valves, and may
especially via the vagus nerve and with the sym- be a sign of heart disease (although many mur-
pathetic system (see NERVOUS SYSTEM). In the murs, especially in children, are innocent).
near part of the atria lies a collection of nerve
cells and connecting fibres, known as the sinu- Action At each heartbeat the two atria con-
atrial node or pacemaker, which forms the tract and expel their contents into the vent-
starting-point for the impulses that initiate ricles, which at the same time they stimulate to
the beats of the heart. In the groove between the contract together, so that the blood is driven
ventricles and the atria lies another collection of into the arteries, to be returned again to the
similar nerve tissue, known as the atrioventricu- atria after having completed a circuit in about
lar node. Running down from there into the 15 seconds through the body or lungs as the
septum between the two ventricles is a band of case may be. The heart beats from 60 to 90
special muscle fibres, known as the atrioven- times a minute, the rate in any given healthy
H tricular bundle, or the bundle of His. This splits person being about four times that of the res-
up into a right and a left branch for the two pirations. The heart is to some extent regulated
ventricles, and the fibres of these distribute by a nerve centre in the MEDULLA, closely con-
themselves throughout the muscular wall of the nected with those centres which govern the
ventricles and control their contraction. lungs and stomach, and nerve fibres pass to it in
the vagus nerve. The heart rate and force can be
Openings There is no direct communica- diminished by some of these fibres, by others
tion between the cavities on the right side and increased, according to the needs of the various
those on the left; but the right atrium opens organs of the body. If this nerve centre is injured
into the right ventricle by a large circular open- or poisoned for example, by lack of oxygen
ing, and similarly the left atrium into the left the heart stops beating in human beings;
ventricle. Into the right atrium open two large although in some of the lower animals (e.g.
veins, the superior and inferior venae cavae, frogs, fishes and reptiles) the heart may under
with some smaller veins from the wall of the favourable conditions go on beating for hours
heart itself, and into the left atrium open two even after its entire removal from the body.
pulmonary veins from each lung. One opening
leads out of each ventricle to the aorta in the Heart, Artificial
case of the left ventricle, to the pulmonary A mechanical device in the chest that enhances
artery from the right. or takes over the pumping action of the HEART,
Before birth, the FETUSs heart has an open- thus maintaining the necessary level of circula-
ing (foramen ovale) from the right into the left tion of blood through the lungs and other body
atrium through which the blood passes; but structures. An artificial heart was first used in
when the child first draws air into his or her humans in 1985 and the three types in use are:
lungs this opening closes and is represented in an intra-aortic balloon pump, driven by com-
the adult only by a depression (fossa ovalis). pressed air, which inflates a balloon in the
AORTA with every heartbeat, increasing the vol-
Valves The heart contains four valves. The ume of circulating blood; an electrical device
mitral valve consists of two triangular cusps; the that assists the left VENTRICLE by pumping
tricuspid valve of three smaller cusps. The aor- blood into the abdominal aorta; and a mechan-
tic and pulmonary valves each consist of three ical artificial heart that replaces a diseased heart
semilunar-shaped segments. Two valves are that has been removed. As yet there is no arti-
placed at the openings leading from atrium into ficial heart suitable for long-term use. Existing
ventricle, the tricuspid valve on the right side, devices are intended to tide over a patient who
the mitral valve on the left, so as completely to is extremely ill until a live heart can be trans-
prevent blood from running back into the planted from a donor. The results from artificial
atrium when the ventricle contracts. Two more, hearts have been disappointing because of
the pulmonary valve and the aortic valve, are at complications and also because the patients
the entrance to these arteries, and prevent have usually been already dangerously ill.
regurgitation into the ventricles of blood which
has been driven from them into the arteries. Heart, Diseases of
The noises made by these valves in closing con- Heart disease can affect any of the structures of
stitute the greater part of what are known as the the HEART and may affect more than one at a
 Heart, Diseases of 321

time. Heart attack is an imprecise term and may the muscle of the heart ventricles. This
refer to ANGINA PECTORIS (a symptom of pain reduces the muscles efficiency, the ventricles
originating in the heart) or to coronary artery fail to relax properly and do not fill suf-
thrombosis, also called myocardial infarction. ficiently during DIASTOLE.
In the dilated type of cardiomyopathy, both
Arrhythmias An abnormal rate or rhythm ventricles overdilate, impairing the efficiency
of the heartbeat. The reason is a disturbance in of contraction and causing congestion of the
the electrical impulses within the heart. Some- lungs.
times a person may have an occasional irregular
heartbeat: this is called an ECTOPIC beat (or an
In the restrictive variety, proper filling of the
ventricles does not occur because the muscle
extrasystole) and does not necessarily mean that walls are less elastic than normal. The result
an abnormality exists. There are two main types is raised pressure in the two atria (upper
of arrhythmia: bradycardias, where the rate is cavities) of the heart: these dilate and develop
slow fewer than 60 beats a minute and some- FIBRILLATION. Diagnosis can be difficult and
times so slow and unpredictable (heartblock) as treatment is symptomatic, with a poor prog-
to cause blackouts or heart failure; and tachy- nosis. In suitable patients, heart TRANSPLAN-
cardia, where the rate is fast more than 100 TATION may be considered.
H
beats a minute. A common cause of arrhythmia Disorders of the heart muscle may also be
is coronary artery disease, when vessels carrying caused by poisoning for example, heavy con-
blood to the heart are narrowed by fatty sumption of alcohol. Symptoms include tired-
deposits (ATHEROMA), thus reducing the blood ness, palpitations (quicker and sometimes
supply and damaging the heart tissue. This irregular heartbeat), chest pain, difficulty in
condition often causes myocardial infarction breathing, and swelling of the legs and hands
after which arrhythmias are quite common and due to accumulation of fluid (OEDEMA). The
may need correcting by DEFIBRILLATION (appli- heart is enlarged (as shown on chest X-ray) and
cation of a short electric shock to the heart). ECHOCARDIOGRAPHY shows thickening of the
Some tachycardias result from a defect in the heart muscle. A BIOPSY of heart muscle will
electrical conduction system of the heart that is show abnormalities in the cells of the heart
commonly congenital. Various drugs can be muscle.
used to treat arrhythmias (see ANTIARRHYTHMIC Where the cause of cardiomyopathy is
DRUGS). If attacks constantly recur, the unknown, as is the case with most patients,
arrhythmia may be corrected by electrical treatment is symptomatic using DIURETICS to
removal of dead or diseased tissue that is the control heart failure and drugs such as DIGOXIN
cause of the disorder. Heartblock is most effect- to return the heart rhythm to normal. Patients
ively treated with an artificial CARDIAC PACE- should stop drinking alcohol. If, as often
MAKER, a battery-activated control unit happens, the patients condition slowly
implanted in the chest. deteriorates, heart transplantation should be
considered.
Cardiomyopathy Any disease of the heart
muscle that results in weakening of its contrac- Congenital heart disease accounts for
tions. The consequence is a fall in the efficiency 12 per cent of all cases of organic heart disease.
of the circulation of blood through the lungs It may be genetically determined and so
and remainder of the body structures. The inherited; present at birth for no obvious rea-
myopathy may be due to infection, disordered son; or, in rare cases, related to RUBELLA in the
metabolism, nutritional excess or deficiency, mother. The most common forms are holes in
toxic agents, autoimmune processes, degener- the heart (atrial septal defect, ventricular septal
ation, or inheritance. Often, however, the cause defect see SEPTAL DEFECT), a patent DUCTUS
is not identified. Cardiomyopathies are less ARTERIOSUS, and COARCTATION OF THE
common than other types of heart diseases, and AORTA. Many complex forms also exist and can
the incidence of different types of myopathy be diagnosed in the womb by fetal echocardi-
(see below) is not known because patients or ography which can lead to elective termination
doctors are sometimes unaware of the presence of pregnancy. Surgery to correct many of these
of the condition. abnormalities is feasible, even for the most
The three recognised groups of cardio- severe abnormalities, but may only be palliative
myopathies are hypertrophic, dilated and giving rise to major difficulties of management
restrictive. as the children become older. Heart transplan-
Hypertrophic myopathy, a familial condi-
tion, is characterised by great enlargement of
tation is now increasingly employed for the
uncorrectable lesions.
 322 Heart, Diseases of

Coronary artery disease Also known as associated with a high level of CHOLESTEROL in
ischaemic heart disease, this is a common cause the blood, which in turn has been linked with
of symptoms and death in the adult population. an excessive consumption of animal, as opposed
It may present for the first time as sudden to vegetable, fats. In this connection the
death, but more usually causes ANGINA PEC- important factors seem to be the saturated fatty
TORIS, myocardial infarction (heart attack) or acids (low-density and very low-density lipo-
heart failure. It can also lead to a disturbance of proteins [LDLs and VLDLs] see CHOLES-
heart rhythm. Factors associated with an TEROL) of animal fats which would appear to
increased risk of developing coronary artery be more likely to lead to a high level of choles-
disease include diabetes, cigarette smoking, terol in the blood than the unsaturated fatty
high blood pressure, obesity, and a raised con- acids of vegetable fats. As more research on the
centration of cholesterol in the blood. Older subject is carried out, the arguments continue
males are most affected. about the relative influence of the different fac-
tors. (For advice on prevention of the disease,
Coronary thrombosis or acute myo- see APPENDIX 2: ADDRESSES: SOURCES OF
cardial infarction is the acute, dramatic INFORMATION, ADVICE, SUPPORT AND SELF-
H manifestation of coronary-artery ischaemic HELP.)
heart disease one of the major killing diseases
of western civilisation. In 1999, ischaemic heart Symptoms The presenting symptom is the
disease was responsible for about 115,000 sudden onset, often at rest, of acute, agonising
deaths in England and Wales, compared with pain in the front of the chest. This rapidly radi-
153,000 deaths in 1988. In 1999 more than ates all over the front of the chest and often
55,600 people died of coronary thrombosis. down over the abdomen. The pain is frequently
The underlying cause is disease of the coronary accompanied by nausea and vomiting, so that
arteries which carry the blood supply to the suspicion may be aroused of some acute abdom-
heart muscle (or myocardium). This results in inal condition such as biliary colic (see GALL-
narrowing of the arteries until finally they are BLADDER, DISEASES OF) or a perforated PEPTIC
unable to transport sufficient blood for the ULCER. The victim soon goes into SHOCK, with
myocardium to function efficiently. One of a pale, cold, sweating skin, rapid pulse and dif-
three things may happen. If the narrowing of ficulty in breathing. There is usually some rise
the coronary arteries occurs gradually, then the in temperature.
individual concerned will develop either angina
pectoris or signs of a failing heart: irregular Treatment is immediate relief of the pain by
rhythm, breathlessness, CYANOSIS and oedema. injections of diamorphine. Thrombolytic drugs
If the narrowing occurs suddenly or leads to should be given as soon as possible (rapid door
complete blockage (occlusion) of a major to needle time) and ARRHYTHMIA corrected.
branch of one of the coronary arteries, then the OXYGEN is essential and oral ASPIRIN is valuable.
victim collapses with acute pain and distress. Treatment within the first hour makes a great
This is the condition commonly referred to difference to recovery. Subsequent treatment
as a coronary thrombosis because it is usually includes the continued administration of drugs
due to the affected artery suddenly becoming to relieve the pain; the administration of
completely blocked by THROMBOSIS. More ANTIARRHYTHMIC DRUGS that may be necessary
correctly, it should be described as coronary to deal with the heart failure that commonly
occlusion, because the final occluding factor develops, and the irregular action of the heart
need not necessarily be thrombosis. that quite often develops; and the continued
administration of oxygen. Patients are usually
Causes The precise cause is not known, but a admitted to coronary care units, where they
wide range of factors play a part in inducing receive constant supervision. Such units main-
coronary artery disease. Heredity is an import- tain an emergency, skilled, round-the-clock
ant factor. The condition is more common in staff of doctors and nurses, as well as all the
men than in women; it is also more common in necessary resuscitation facilities that may be
those in sedentary occupations than in those required.
who lead a more physically active life, and more The outcome varies considerably. The first
likely to occur in those with high blood pressure (golden) hour is when the patient is at greatest
than in those with normal blood pressure (see risk of death: if he or she is treated, then there is
HYPERTENSION). Obesity is a contributory fac- a 50 per cent reduction in mortality compared
tor. The disease is more common among with waiting until hospital admission. As each
smokers than non-smokers; it is also often day passes the prognosis improves with a first
 Heart-Lung Machine 323

coronary thrombosis, provided that the patient tion, infection and a congenital weakness (pro-
does not have a high blood pressure and is not lapse). The valve may also leak if stretched by a
overweight. Following recovery, there should be dilating ventricle (functional incompetence).
a gradual return to work, care being taken to Infection (endocarditis) may affect the valve in
avoid any increase in weight, unnecessary stress a similar way to aortic disease. Mitral symptoms
and strain, and to observe moderation in all are predominantly breathlessness which may
things. Smoking must stop. In uncomplicated lead to wheezing or waking at night breathless
cases patients get up and about as soon as pos- and needing to sit up or stand for relief. They
sible, most being in hospital for a week to ten are made worse when the heart rhythm changes
days and back at work in three months or (atrial fibrillation) which is frequent as the dis-
sooner. ease becomes more severe. This leads to a loss of
efficiency of up to 25 per cent and a predis-
Valvular heart disease primarily affects position to clot formation as blood stagnates
the mitral and aortic valves which can become rather than leaves the heart efficiently. Mitral
narrowed (stenosis) or leaking (incompetence). incompetence may remain mild and be of no
Pulmonary valve problems are usually con- trouble for many years, but infection must be
genital (stenosis) and the tricuspid valve is guarded against (endocarditis prophylaxis). H
sometimes involved when rheumatic heart dis-
ease primarily affects the mitral or aortic valves. Endocarditis is an infection of the heart
RHEUMATIC FEVER, usually in childhood, which may acutely destroy a valve or may lead
remains a common cause of chronic valvular to chronic destruction. Bacteria settle usually
heart disease causing stenosis, incompetence or on a mild lesion. Antibiotics taken at vulnerable
both of the aortic and mitral valves, but each times can prevent this (antibiotic prophylaxis)
valve has other separate causes for malfunction. for example, before tooth extraction. If estab-
lished, lengthy intravenous antibiotic therapy is
Aortic valve disease is more common needed and surgery is often necessary. The mor-
with increasing age. When the valve is nar- tality is 30 per cent but may be higher if the
rowed, the heart hypertrophies and may later infection settles on a replaced valve (prosthetic
fail. Symptoms of angina or breathlessness are endocarditis). Complications include heart
common and dizziness or blackouts (syncope) failure, shock, embolisation (generation of
also occur. Replacing the valve is a very effective small clots in the blood), and cerebral (mental)
treatment, even with advancing age. Aortic confusion.
stenosis may be caused by degeneration (senile PERICARDITIS is an inflammation of the sac
calcific), by the inheritance of two valvular leaf- covering the outside of the heart. The sac
lets instead of the usual three (bicuspid valve), or becomes roughened and pain occurs as the
by rheumatic fever. Aortic incompetence again heart and sac rub together. This is heard by
leads to hypertrophy, but dilatation is more stethoscope as a scratching noise (pericardial
common as blood leaks back into the ventricle. rub). Fever is often present and a virus the main
Breathlessness is the more common complaint. cause. It may also occur with rheumatic fever,
The causes are the same as stenosis but also kidney failure, TUBERCULOSIS or from an
include inflammatory conditions such as SYPH- adjacent lung problem such as PNEUMONIA or
ILIS or ANKYLOSING SPONDYLITIS and other cancer. The inflammation may cause fluid to
disorders of connective tissue. The valve may accumulate between the sac and the heart (effu-
also leak if the aorta dilates, stretching the valve sion) which may compress the heart causing a
ring as with HYPERTENSION, aortic ANEURYSM fall in blood pressure, a weak pulse and circula-
and MARFANS SYNDROME an inherited dis- tory failure (tamponade). This can be relieved
order of connective tissue that causes heart by aspirating the fluid. The treatment is then
defects. Infection (endocarditis) can worsen directed at the underlying cause.
acutely or chronically destroy the valve and
sometimes lead to abnormal outgrowths on the Heart-Lung Machine
valve (vegetations) which may break free and A device that temporarily takes over the func-
cause devastating damage such as a stroke or tion of the heart and lungs. It is used in certain
blocked circulation to the bowel or leg. operations in the chest, giving the surgeon more
time for operations such as open-heart surgery,
Mitral valve disease leading to stenosis is heart transplants and heart-lung transplants.
rheumatic in origin. Mitral incompetence may The machine also ensures an operating area
be rheumatic but in the absence of stenosis can largely free of blood, which helps the surgeon to
be due to ISCHAEMIA, INFARCTION, inflamma- work more quickly. A pump replaces the heart
 324 Heart-Lung Transplant

and an oxygenator replaces the lungs. When system requires complex drug treatment. But
connected up, the machine in effect bypasses once the patient has passed the immediate post-
normal cardiopulmonary activity. It also con- operative phase, the chances of five-year sur-
tains a heat exchanger to warm or cool the vival is as high as 80 per cent in some cardiac
patients blood according to the requirements centres. A key difficulty in doing heart trans-
of the operation. The patient is given an anti- plants is a serious shortage of donor organs.
coagulant (HEPARIN) to counteract clotting
which may occur when blood cells get damaged Heartburn
during the machines use. Patients are on the A burning sensation experienced in the region
machine for a few hours only, because blood of the heart and up the back to the throat. It is
supply to vital organs begins to be reduced. caused by an excessive acidity of the gastric juice
often aggravated by dietary indiscretions
Heart-Lung Transplant and is relieved temporarily by taking alkaline
An operation in which a patients diseased substances, such as 12 grams of bicarbonate of
lungs and heart are removed and replaced with soda, or commercial preparations such as
donor organs from someone who has been cer- aluminium-containing antacid tablets (e.g.
H tified as brain dead (see BRAIN-STEM DEATH). Aluminium Hydroxide Tablets) or prescribed
As well as the technical difficulties of such an drugs such as lansoprazole. The frequency of
operation, rejection by the recipients tissues of heartburn attacks can be lessened by eating a
donated heart and lungs has proved hard to sensible diet, avoiding fatty or indigestible
overcome. Since the early 1990s, however, foods and restricting alcohol consumption.
immunosuppressant drug therapy Persistent heartburn may be a sign of more
(see CICLOSPORIN; TRANSPLANTATION) has serious oesophageal disease and medical advice
facilitated the regular use of this type of surgery. should be sought.
Even so, patients receiving transplanted hearts
and lungs face substantial risks such as lung Heat Cramps
infection and airway obstruction as well as the Painful cramps in the muscles occurring in
long-term problems of transplant rejection. workers, such as stokers, who labour in hot
conditions. The cramps are the result of loss of
Heart Surgery salt in the sweat, and can be cured by giving the
Open-heart surgery permits the treatment of sufferer salty water to drink. (See also HEAT
many previously inoperable conditions that STROKE.)
were potentially fatal, or which made the
patient chronically disabled. CORONARY ARTERY Heat Spots
VEIN BYPASS GRAFTING (CAVBG), used to rem- A vague term applied to small inflamed and
edy obstruction of the arteries supplying the congested areas which appear especially upon
heart muscle, was first carried out in the mid- the skin of the face, neck and chest or other
1960s and is now widely practised. Constricted parts of the body in warm weather.
heart valves today are routinely dilated by tech-
niques of MINIMALLY INVASIVE SURGERY (MIS), Heat Stroke
such as ANGIOPLASTY and laser treatment, and A condition resulting from environmental tem-
faulty valves can be replaced with mechanical peratures which are too high for compensation
alternatives (see VALVULOPLASTY). by the bodys thermo-regulatory mechanism(s).
It is characterised by hyperpyrexia, nausea,
Heart transplant Replacement of a per- headache, thirst, confusion, and dry skin. If
sons unhealthy heart with a normal heart from untreated, COMA and death ensue. The occur-
a healthy donor. The donors heart needs to be rence of heat stroke is sporadic: whereas a single
removed immediately after death and kept individual may be affected (occasionally with
chilled in saline before rapid transport to the fatal consequences), his or her colleagues may
recipient. Heart transplants are technically remain unaffected. Predisposing factors include
demanding operations used to treat patients unsatisfactory living or working conditions,
with progressive untreatable heart disease but inadequate acclimatisation to tropical condi-
whose other body systems are in good shape. tions, unsuitable clothing, underlying poor
They usually have advanced coronary artery health, and possibly dietetic or alcoholic
disease and damaged heart muscle (CARDIO- indiscretions. The condition can be a major
MYOPATHY). Apart from the technical difficul- problem during pilgrimages for example, the
ties of the operation, preventing rejection of the Muslim Hadj. Four clinical syndromes are
transplanted heart by the recipients immune recognised:
 HELLP Syndrome 325

Heat collapse is characterised by fatigue, Hebephrenia

giddiness, and temporary loss of consciousness. A form of SCHIZOPHRENIA that comes on in
It is accompanied by HYPOTENSION and youth and is marked by depression and gradual
BRADYCARDIA; there may also be vomiting and failure of mental faculties with egotistic and
muscular cramps. Urinary volume is dimin- self-centred delusions.
ished. Recovery is usual.
Heberdens Nodes
Heat exhaustion is characterised by Small hard knobs which appear at the sides of
increasing weakness, dizziness and insomnia. In the last phalanges of the fingers in people who
the majority of sufferers, sweating is defective; have OSTEOARTHRITIS.
there are few, if any, signs of dehydration. Pulse
rate is normal, and urinary output good. Body Heel
temperature is usually 378383 C. The heel is the hind part of the foot, formed by
the CALCANEUS and the especially thick skin
Heat cramps (usually in the legs, arms or covering it. It is not subject to many diseases.
back, and occasionally involving the abdom- Severe pain in the heel is sometimes a sign of
inal muscles) are associated with hard physical gout or rheumatism. H
work at a high temperature. Sweating, pallor,
headache, giddiness and intense anxiety are Height
present. Body temperature is only mildly See WEIGHT AND HEIGHT.
raised.
Helicobacter Pylori
Heat hyperpyrexia is heralded by energy A bacterium which colonises the stomach.
loss and irritability; this is followed by mental While it may cause no disease, it has a tendency
confusion and diminution of sweating. The to produce inflammation gastritis. This may
individual rapidly becomes restless, then coma- progress in some people to peptic ulceration (see
tose; body temperature rises to 4142 C or PEPTIC ULCER), and even to gastric cancer. The
even higher. The condition is fatal unless bacterium can be identified on blood testing or,
expertly treated as a matter of urgency. more accurately, by obtaining a biopsy of the
stomach wall by ENDOSCOPY. It can be eradi-
Treatment With the first two syndromes, the cated by treatment with PROTON-PUMP INHIBI-
affected individual must be removed immedi- TORS and antibiotics.
ately to a cool place, and isotonic saline admin-
istered intravenously in a severe case. The Heliotherapy
fourth syndrome is a medical emergency. The Sunbathing; the exposure of the body to sun-
patient should be placed in the shade, stripped, light to promote healing.
and drenched with water; fanning should be
instigated. He or she should be wrapped in a Helium
sheet soaked in cool water and fanning con- This is the lightest gas known, with the excep-
tinued. When rectal temperature has fallen to tion of hydrogen. This property renders it of
39 C, the patient is wrapped in a dry blanket. value in ANAESTHESIA, as its addition to the
Immediately after consciousness returns, nor- anaesthetic means that it can be inhaled with
mal saline should be given orally; this usually less effort by the patient. Thus it can be used in
provokes sweating. The risk of circulatory col- the presence of any obstruction to the entry of
lapse exists. Convalescence may be protracted air to the lungs.
and the patient should be repatriated to a cool
climate. Prophylactically, personnel intended HELLP Syndrome
for work in a tropical climate must be very care- A type of severe PRE-ECLAMPSIA (a disorder
fully selected. Adequate acclimatisation is also affecting some pregnant women) that affects
essential; severe physical exertion must be various systems in the body. HAEMOLYSIS, raised
avoided for several weeks, and light clothes concentration of the enzymes in the LIVER, and
should be worn. The diet should be light but a low blood platelet count are among the char-
nourishing, and fluid intake adequate. Those acteristics (and explain the name HELLP);
performing hard physical work at a very high patients are acutely ill and immediate termin-
ambient temperature should receive sodium ation of pregnancy is necessary. (See also PREG-
chloride supplements. Attention to ventilation NANCY AND LABOUR.)
and air-conditioning is essential; fans are also of
value.
 326 Helminths

Helminths body. This most commonly follows a STROKE

Another name for parasitic worms such as and occurs when parts of the brain serving
FLUKES, tapeworms (see TAENIASIS) and nema- motor function on the opposite side of the
todes (see ASCARIASIS). body are damaged.

Hemianaesthesia Hemiplegia
Loss of the sense of touch down one side of the PARALYSIS that is limited to one side of the body.
body.
Hemp
Hemianopia See CANNABIS.
A term meaning loss of half the usual area of
vision. The affected person may see everything Henle, Loop of
clearly to the left or to the right, the field of That part of the nephron (see KIDNEYS) between
vision stopping abruptly at the middle line; the proximal and distal convoluted tubules. It
they may see things only when straight ahead of extends into the renal medulla as a hairpin-
them; or, thirdly, they may see objects far out shaped loop. The ascending link of the loop
H on both sides, although there is a wide area actively transports sodium from the lumen of
straight in front for which they are quite blind. the tube to the interstitium, and this, combined
The position of the blind area is important in with the counter-current flow of fluid through
localising the position in the brain of the disease the two limbs of the loop, plays a part in con-
responsible for the condition. centrating the urine.

Hemiatrophy Henoch-Schnlein Purpura

Atrophy of one side of the body, or of part of This is an inflammatory condition of the small
the body on one side: for example, facial hemia- blood vessels, the cause of which is not known
trophy, in which one-half of the face is smaller but may be an allergic response to food or
than the other, either in the course of develop- drugs. Most common among young children,
ment or as a result of some nervous disorder. the inflammation causes blood to leak into
joints, kidneys, intestine and skin. The child
Hemiballismus presents with a purpuric rash and stomach
Involuntary movements similar to choreiform pains which may come and go for weeks. Para-
(see CHOREA) movements, but of much greater cetamol alone is often sufficient to alleviate the
amplitude and force. The violent, throwing condition, but severely ill patients may need
movements of the limbs are usually unilateral, corticosteroid drugs. All sufferers need follow-
and tend to occur acutely as a result of vascular up for 12 months to ensure that they have not
damage to the mid-brain. developed kidney disease.

Hemicolectomy Heparin
An operation to remove the right or left half of Heparin is one of the naturally produced ANTI-
the COLON, usually with end-to-end ANASTO- COAGULANTS with a rapid effect, which is
MOSIS of the remaining portion of the intestine. thought to act by neutralising thrombin (see
This is often used for the treatment of malig- COAGULATION). Inactive when taken orally, it is
nant or inflammatory diseases of the colon. normally given intravenously it may be
given for a few days, combined with an oral
Hemicrania anticoagulant such as warfarin, to initiate anti-
A headache limited to one side of the head. (See coagulation. Low-dose heparin may be given by
also MIGRAINE.) subcutaneous injection for longer periods, for
the prophylaxis of DEEP VEIN THROMBOSIS
Hemimelia (DVT) or PULMONARY EMBOLISM in high-risk
This consists of defects in the distal part of the patients, such as those with obesity or a his-
extremities: for example, the absence of a fore- tory of thrombosis, or post-operatively. If
arm or hand. Hemimelia is a congenital defect; haemorrhage occurs, withdrawal of heparin is
large numbers of cases resulted from the usually sufficient, but protamine sulphate is a
administration of THALIDOMIDE during preg- rapidly active and specific antidote. Prolonged
nancy (see also PHOCOMELIA; TERATOGENESIS). treatment with heparin may cause osteoporosis
(see under BONE, DISORDERS OF).
Hemiparesis
Paralysis affecting the muscles of one side of the
 Hepatitis 327

Hepatectomy discomfort and production of abnormal

The operation for removal of the LIVER, or part amounts of wind. Initially, the liver may
of it. enlarge, but later it becomes hard and
shrunken, though rarely causing pain. Skin
Hepatic Encephalopathy pigmentation may occur along with jaundice,
A neuropsychiatric syndrome caused by disease the result of failure to excrete the liver product
of the LIVER, and occurring most often in BILIRUBIN. Routine liver-function tests on
patients with CIRRHOSIS see also LIVER, DIS- blood are used to help diagnose the disease and
EASES OF; it also occurs in acute form in acute to monitor its progress. Spider telangiectasia
failure of liver function. The disorder is (caused by damage to blood vessels see TEL-
believed to be the result of biochemical disturb- ANGIECTASIS) usually develop, and these are a
ance of brain function, because the condition is significant pointer to liver disease. ENDOCRINE
reversible and pathological changes in brain tis- changes occur, especially in men, who lose their
sue are rarely found. The patients intellect, per- typical hair distribution and suffer from atro-
sonality, emotions and consciousness are altered phy of their testicles. Bruising and nosebleeds
but neurological signs may or may not be iden- occur increasingly as the cirrhosis worsens, and
tified. Apathy, confusion, drowsiness, some- portal hypertension (high pressure of venous H
times CONVULSIONS, speech disturbance and blood circulation through the liver) develops
eventually COMA mark the progress of the con- due to abnormal vascular resistance. ASCITES
dition. The principles of treatment are to and HEPATIC ENCEPHALOPATHY are indications
remove the precipitating causes. These include: of advanced cirrhosis.
URAEMIA; sedative, antidepressant and hypnotic Treatment of cirrhosis is to tackle the under-
drugs; gastrointestinal bleeding; too much pro- lying cause, to maintain the patients nutrition
tein in the diet; infection; and trauma (includ- (advising him or her to avoid alcohol), and to
ing surgical operations). treat any complications. The disorder can also
be treated by liver transplantation; indeed, 75
Hepatitis per cent of liver transplants are done for cir-
Inflammation of the LIVER which damages liver rhosis. The overall prognosis of cirrhosis, how-
cells and may ultimately kill them. Acute injury ever, is not good, especially as many patients
of the liver is usually followed by complete attend for medical care late in the course of the
recovery, but prolonged inflammation after disease. Overall, only 25 per cent of patients
injury may result in FIBROSIS and CIRRHOSIS. live for five years after diagnosis, though
Excluding trauma, hepatitis has several causes: patients who have a liver transplant and survive
Viral infections by any of hepatitis A, B, C, for a year (80 per cent do) have a good
D, or E viruses and also CYTOMEGALOVIRUS prognosis.
(CMV), EPSTEIN BARR VIRUS, and HERPES
SIMPLEX. Autoimmune hepatitis is a type that
Autoimmune disorders such as autoimmune
chronic hepatitis, toxins, alcohol and certain
most commonly occurs in women between 20
and 40 years of age. The cause is unknown and
drugs ISONIAZID, RIFAMPICIN, HALOTHANE it has been suggested that the disease has several
and CHLORPROMAZINE. immunological subtypes. Symptoms are similar
WILSONS DISEASE.
Acute viral hepatitis causes damage through-
to other viral hepatitis infections, with painful
joints and AMENORRHOEA as additional
out the liver and in severe infections may des- symptoms. Jaundice and signs of chronic liver
troy whole lobules (see below). disease usually occur. Treatment with CORTI-
Chronic hepatitis is typified by an invasion COSTEROIDS is life-saving in autoimmune hepa-
of the portal tract by white blood cells (mild titis, and maintenance treatment may be
hepatitis). If these mononuclear inflammatory needed for two years or more. Remissions and
cells invade the body (parenchyma) of the liver exacerbations are typical, and most patients
tissue, fibrosis and then chronic disease or cir- eventually develop cirrhosis, with 50 per cent of
rhosis can develop. Cirrhosis may develop at victims dying of liver failure if not treated. This
any age and commonly results in prolonged ill figure falls to 10 per cent in treated patients.
health. It is an important cause of premature
death, with excessive alcohol consumption Viral hepatitis The five hepatic viruses (A
commonly the triggering factor. Sometimes, to E) all cause acute primary liver disease,
cirrhosis may be asymptomatic, but common though each belongs to a separate group of
symptoms are weakness, tiredness, poor appe- viruses.
tite, weight loss, nausea, vomiting, abdominal Hepatitis A virus (HAV) is an ENTEROVIRUS
 328 Hepatocyte

which is very infectious, spreading by faecal As well as blood tests to assess liver function,
contamination from patients suffering from there are specific virological tests to identify the
(or incubating) the infection; victims excrete five infective agents, and these are important
viruses into the faeces for around five weeks contributions to diagnosis. However, there is no
during incubation and development of the specific treatment of any of these infections.
disease. Overcrowding and poor sanitation The more seriously ill patients may require
help to spread hepatitis A, which fortunately hospital care, mainly to enable doctors to spot
usually causes only mild disease. at an early stage those developing acute liver
Hepatitis B (HBV) is caused by a hepadna failure. If vomiting is a problem, intravenous
virus, and humans are the only reservoir of fluid and glucose can be given. Therapeutic
infection, with blood the main agent for drugs especially sedatives and hypnotics
transferring it. Transfusions of infected blood should be avoided, and alcohol must not be
or blood products, and injections using con- taken during the acute phase. Interferon is the
taminated needles (common among habitual only licensed drug for the treatment of chronic
drug abusers), are common modes of trans- hepatitis B, but this is used with care.
fer. Tattooing and ACUPUNCTURE may Otherwise-fit patients under 40 with acute
H spread hepatitis B unless high standards of viral hepatitis have a mortality rate of around
sterilisation are maintained. Sexual inter- 0.5 per cent; for those over 60, this figure is
course, particularly between male homo- around 3 per cent. Up to 95 per cent of adults
sexuals, is a significant infection route. with acute HBV infection recover fully but the
Hepatitis C (HCV) is a flavivirus whose rest may develop life-long chronic hepatitis,
source of infection is usually via blood con- particularly those who are immunodeficient (see
tacts. Effective screening of blood donors and IMMUNODEFICIENCY).
heat treatment of blood factors should pre- Infection is best prevented by good living
vent the spread of this infection, which conditions. HVA and HVB can be prevented
becomes chronic in about 75 per cent of by active immunisation with vaccines. There is
those infected, lasting for life. Although most no vaccine available for viruses C, D and E,
carriers do not suffer an acute illness, they although HDV is effectively prevented by
must practise life-long preventive measures. immunisation against HBV. At-risk groups
Hepatitis D (HDV) cannot survive
independently, needing HBV to replicate, so
who should be vaccinated against HBV
include:
its sources and methods of spread are similar Parenteral drug abusers.
to the B virus. HDV can infect people at
the same time as HBV, but it is capable of
Close contacts of infected individuals such as
regular sexual partners and infants of
superinfecting those who are already chronic infected mothers.
carriers of the B virus. Acute and chronic Men who have sex with men.
infection of HDV can occur, depending on Patients undergoing regular haemodialysis.
individual circumstances, and parenteral
drug abuse spreads the infection. The disease
Selected health professionals, including
laboratory staff dealing with blood samples
occurs worldwide, being endemic in Africa, and products.
South America and the Mediterranean
littoral. Hepatocyte
Hepatitis E virus (HEV) is excreted in the The main cell type present in the LIVER. A large
stools, spreading via the faeco-oral route. It cell, it has several important metabolic func-
causes large epidemics of water-borne hepa- tions: these include synthesis and storage of
titis and flourishes wherever there is poor biochemical products; detoxification of poisons
sanitation. It resembles acute HAV infection and unwanted substances; and the manufacture
and the patient usually recovers. HEV does of BILE, the liver secretion that passes through
not cause chronic infection. the bile ducts to the small intestine and helps in
The clinical characteristics of the five hepatic the digestion of fat.
viruses are broadly similar. The initial symp-
toms last for up to two weeks (comprising tem- Hepatolenticular Degeneration
perature, headache and malaise), and JAUNDICE See WILSONS DISEASE.
then develops, with anorexia, nausea, vomiting
and diarrhoea common manifestations. Upper Hepatoma
abdominal pain and a tender enlarged liver A primary malignant tumour of LIVER cells. It
margin, accompanied by enlarged cervical has marked geographical variation, being most
lymph glands, are usual. common in parts of Africa and the Far East. It is
 Hernia 329

more common in men and with those who have involve the organs of the abdomen which can
pre-existing CIRRHOSIS. herniate externally through the abdominal wall,
or internally usually through a defect in the
Hepatomegaly diaphragm. External hernias appear as a swell-
Enlargement of the LIVER. This may be caused ing, covered with skin, which bulges out on
by congestion (e.g. in heart failure), infection coughing or straining but which can normally
(e.g. HEPATITIS), malignancy, inflammation, or be made to disappear with gentle pressure.
early CIRRHOSIS.
Types Inguinal hernia appears in the groin;
Hepolenticular Degeneration less common is femoral hernia, which appears
See WILSONS DISEASE.
just below the groin. Incisional hernia may
occur through a defect in any abdominal surgi-
Herbal Medicine cal scar, a paraumbilical hernia arising just to
The use of herbs as medicines is probably as old the side of the umbilicus and an epigastric her-
as mankind; every culture has its own tradi- nia in the mid line above the umbilicus. In
tions. Herbalism was formally established in children, herniation may occur through the
England by an Act of Parliament during Henry umbilicus itself, which is a natural weak spot. H
VIIIs reign. Different parts of a variety of The commonest internal hernia is a hiatus her-
plants are used to treat symptoms and to restore nia, when part of the stomach slips upwards
functions. into the chest through the DIAPHRAGM (see
diagram).
Heredity
The principle on which various peculiarities of
bodily form or structure, or of physical or men-
tal activity, are transmitted from parents to off-
spring. (See also GENES.)

Hermaphrodite
An individual in whom both ovarian (see OVAR-
IES) and testicular (see TESTICLE) tissue is pres-
ent. Hermaphrodites may have a testis on one
side and an ovary on the other; or an ovotestis
on one side and an ovary or testis on the other;
or there may be an ovotestis on both sides. Both
gonads are usually intra-abdominal. The true
hermaphrodite usually has a UTERUS and at
least one Fallopian tube (see FALLOPIAN TUBES)
on the side of the ovary, and on the side of the
testis there is usually a VAS DEFERENS. Most true
hermaphrodites are raised as males, but external
virilisation is not usually complete. Even when
significant phallic development is present,
HYPOSPADIAS and CRYPTORCHIDISM are com-
mon. At puberty, GYNAECOMASTIA develops
and MENSTRUATION is common, as ovarian
function is usually more nearly normal than tes-
ticular function. The condition is rare. A more
common condition is pseudohermaphroditism:
these are individuals who possess the gonads of
only one sex but whose external genitalia may
be ambiguous. The cause is a hormonal imbal-
ance and can usually be corrected by hormone
treatment.

Hernia
The protrusion of an organ, or part of an organ, Anatomy of indirect inguinal hernia: area 11 is
through the wall of the cavity that normally where the displaced loop of intestine intrudes into
contains it. The most common types of hernia scrotum.
 330 Hernioplasty

Diaphragmatic or hiatus hernia showing the stomach pushing through the diaphragm into the chest
cavity.

Complications Small hernias may cause no

problems at all. However, some may be large
and cumbersome, or may give rise to a dragging
sensation or even pain.
Although most reduce spontaneously under
the effects of gravity or gentle pressure, any
organs that may have been displaced inside
some hernias may become stuck, when they are
said to be irreducible. If the contents become so
trapped that their blood supply is cut off, then
strangulation occurs. This is a surgical emer-
gency because the strangulated organs will soon
die or rupture. When strangulation usually of
a loop of intestine does occur, the hernia
becomes irreducible, red, and very painful. If
the hernia contains bowel, then the bowel may
also become obstructed.

Treatment Conservative treatment with a

compression belt, or truss, is now used only for
those unfit for surgery or while awaiting sur-
Site of inguinal hernia (shaded). gery. Surgical repair can be at an open operation
or by laparoscope, and consists of returning the
Causes Hernias may be due to a defect pres- herniated organs to their proper place and then
ent at birth (congenital), or may develop later repairing the defect through which the hernia
in life (acquired). Acquired hernias arise due to occurred. This may be done safely under local
the development of a defect or injury of the or general anaesthetic, often as a day-case pro-
abdominal wall or due to increased pressure cedure, and most operative repairs result in a
within the abdominal cavity, which forces the permanent cure.
organ through a potential weakness. Such
causes include chronic coughing or excessive Hernioplasty
straining due to constipation. A surgical technique for repair of a HERNIA.
 Herpes Simplex 331

The abnormal opening is sewn up or the weak- cases of genital herpes are reported annually
ness strengthened with sutures or the insertion from clinics dealing with SEXUALLY TRANSMIT-
of a polypropylene mesh. TED DISEASES (STDS) in England, but there are
also many unrecognised (by either patient or
Herniorraphy doctor) infections. Patients may have a history
Surgical repair of a HERNIA. This may be done of painful attacks of ulceration of the genitals
as an open operation or as MINIMALLY INVASIVE for many years before seeking medical advice.
SURGERY (MIS) using a LAPAROSCOPE. All patients with a first episode of the infection
should be given oral antiviral treatment, and
Herniotomy those who suffer more than six attacks a year
The surgical removal of the sac of connective should be considered for suppressive antiviral
tissue surrounding a HERNIA. In children or treatment. ACICLOVIR, valaciclovir and famci-
healthy young adults with an inguinal hernia, a clovir are all effective antiviral drugs. If a
herniotomy is usually sufficient to cure the woman in the final three months of her preg-
condition. nancy contracts herpes genitalis, this can have
serious consequences for the baby as he or she
Heroin will be at risk of herpes encephalitis after H
Also known as diacetyl morphine or diamor- delivery.
phine, this Class A controlled drug is an opiate
a group which includes morphine, codeine, Herpes Simplex
pethidine and methadone. It is a powerful An acute infectious disease, characterised by the
analgesic and cough suppressant, but its cap- development of groups of superficial vesicles, or
acity to produce euphoria rapidly induces blebs, in the skin and mucous membrane. It is
DEPENDENCE. Popular with addicts, its mostly due to either simplex type 1 or 2 virus, and
pleasant effects soon produce TOLERANCE; the infection can occur at any time from birth
need to inject the drug, with associated risks of onwards; however the usual time for primary
HIV infection, has affected its use by addicts. infection with type 1 is between the second and
Withdrawal symptoms include restlessness, 15th year. Once an individual is infected, the
insomnia, muscle cramps, vomiting and virus persists in the body for the rest of their
diarrhoea; signs include dilated pupils, raised life. It is one of the causes of scrum-pox. Type 2
pulse rate, and disturbed temperature control. causes HERPES GENITALIS.
Although rarely life-threatening, the effects of
withdrawal may cause great distress, and for this Symptoms Symptoms vary with the age of
reason methadone, which has a slower and less infection. In young infants, herpes simplex may
severe withdrawal syndrome, is commonly used cause a generalised infection which is some-
when weaning addicts off heroin. Legally still times fatal. In young children the infection is
available to doctors in the UK, heroin is nor- usually in the mouth, and this may be associ-
mally only used in patients with severe pain, or ated with enlargement of the glands in the
to comfort the dying. neck, general irritability and fever. The condi-
tion usually settles in 710 days. In adults the
Herpangina vesicles may occur anywhere in the skin or
Herpangina is a short febrile illness in which mucous membranes: the more common sites
minute vesicles or punched-out ulcers develop are the lips, mouth and face, where they are
in the posterior parts of the mouth. It is due to known as cold sores. The vesicles may also
infection with the group A COXSACKIE VIRUSES. appear on the genitalia (herpes genitalis) or
in the conjunctiva or cornea of the EYE, and the
Herpes Genitalis brain may be infected, causing ENCEPHALITIS or
An infection of the genitals (see GENITALIA) of MENINGITIS. The first sign is the appearance of
either sex, caused by HERPES SIMPLEX virus type small painful swellings; these quickly develop
2. It is mostly acquired as a result of sexual into vesicles which contain clear fluid and are
activity; some cases are caused by simplex type surrounded by a reddened area of skin. Some
1. After initial infection the virus lies latent in people are particularly liable to recurrent
the dorsal nerve root ganglion (of the spinal attacks, and these often tend to be associated
cord) which enervates the affected area of the with some debilitating condition or infection,
skin. Latent virus is never cured and reactiva- such as pneumonia.
tion results in either a recurrence of symptoms Except in the case of herpes of the cornea, the
or in asymptomatic shedding of the virus which eruption clears completely unless it becomes
then infects a sexual partner. Around 30,000 contaminated with some other organism. In the
 332 Herpes Viruses

case of the cornea, there may be residual scar- blebs or vesicles, as they are known are
ring, which may impair vision. seen on the skin of the back, of the side, or of
the front of the chest, or simultaneously on all
Treatment Aciclovir is effective both topic- three, the points corresponding to the space
ally as cream or eye drops or orally. In severe between one pair of ribs right around. These
systemic infections it can be given blebs increase in number for some days, and
intravenously. spread until there is often a complete half-
girdle around one side of the chest. The pain
Herpes Viruses in this stage is severe, but it appears to vary a
One member of a group of viruses containing good deal with age, being slight in children
DNA which cause latent infections in animals and very severe in old people, in whom indeed
and humans. Viruses from this group cause herpes sometimes forms a serious illness. After
HERPES SIMPLEX, HERPES ZOSTER (shingles) and one or two weeks, most of the vesicles have
CHICKENPOX, and include CYTOMEGALOVIRUS dried up and formed scabs. The pain may not
(CCMV) and EPSTEIN-BARR VIRUS. pass off when the eruption disappears, but
may remain for weeks or even months a
H Herpes Zoster condition known as post-herpetic NEURALGIA.
Herpes zoster, or shingles, is a skin eruption Old people are prone to develop this
of acute nature, closely related to CHICKENPOX condition.
and consisting in the appearance of small yellow
vesicles, which spread over an area, dry up, Treatment ACICLOVIR or famciclovir can be
and heal by scabbing. It receives its name from given orally, and are effective if started in large
the Greek word for a circingle or girdle, doses early in the attack. Later, topical anti-
because it spreads in a zone-like manner along biotics may be required. Analgesics may be
the intercostal nerves around half the chest. necessary if neuralgia is severe.
Herpes of the face also occurs, particularly on
the brow and around the eye. Hertz
The SI (International System of Units) unit of
Causes Shingles is due to the same virus that frequency. It indicates the number of cycles
causes chickenpox. This invades the ganglia of per second (c/s). The abbreviation for hertz is
the nerves, particularly the spinal nerves of the Hz.
chest and the fifth cranial nerve which supplies
the face. Despite being due to the same virus as Heterograft
chickenpox, it is rare for herpes zoster to occur A transplant from one animal to another of a
as a result of contact with a case of chickenpox. different species. It is also known as a xenograft.
On the other hand, it is not unusual for a
patient with herpes zoster to infect a child with Heterosexual
chickenpox. It is a disease of adults rather than Sexual attraction to individuals of the opposite
children, and the older the person, the more sex. (See also HOMOSEXUALITY.)
likely he or she is to develop the disease. Thus
in adults under 50, the incidence is around 25 Heterozygous
per 1,000 people a year; between 50 and 60 it is An individual having dissimilar members of the
around 5 per 1,000; whilst in octogenarians it is pair of genes coding for a given characteristic
10 per 1,000. Occasionally it may be associated (see GENES).
with some serious underlying disease such as
LEUKAEMIA, LYMPHADENOMA, or multiple Hexachlorophene
myeloma (see MYELOMATOSIS). A widely used antiseptic (see ANTISEPTICS)
which is active against a range of micro-
Symptoms The first symptoms are much organisms, including gram-positive and gram-
like those of any feverish attack. The person negative organisms (see GRAMS STAIN), Shigella
feels unwell for some days, has a slight rise of dysenteriae, and Salmonella typhi. One of its
temperature, and feels vague pain in the side advantages is that it retains its activity in the
or in various other parts. Often the area of presence of soap, and is therefore often used in
skin to be affected feels hypersensitive (hyper- soaps and creams in a concentration of 12 per
aesthesia) as though something were rubbing cent. It must be used with caution in babies as it
on it. The pain finally settles at a point in the can be absorbed through the skin and prove
side, and, two or three days after the first harmful. Hexachlorophene must not be used
symptoms, the rash appears. Minute yellow on burned or excoriated skin.
 Hippocratic Oath 333

Hexamine Hindbrain
A substance which, when excreted by the kid- That part of the BRAIN comprising the cerebel-
neys, releases formaldehyde which has an lum, pons and medulla oblongata.
antiseptic action. It is given to patients with
recurrent CYSTITIS. It acts only in urine with Hip
an acid reaction, and, if the urine is alkaline, That part of the body on each side of the pelvis
ascorbic acid may acidify it. Hexamine is used where it articulates with the head of the femur
prophylactically and for long-term treatment of (thigh bone).
recurrent urinary-tract infections.
Hip-Joint
Hg The joint formed by the head of the thigh bone
The chemical symbol for mercury. BLOOD and the deep, cup-shaped hollow on the side of
PRESSURE was traditionally measured in milli- the pelvis which receives it (acetabulum). The
metres (mm) of mercury using a SPHYGMO- joint is of the ball-and-socket variety, is dis-
MANOMETER consisting of an inflatable cuff located only by very great violence, and is cor-
(usually wrapped round the upper arm) con- respondingly difficult to reduce to its natural
nected by a rubber tube to a column of mercury state after dislocation. It is enclosed by a cap-
calibrated in mm of mercury.
H
sule of fibrous tissue, strengthened by several
bands, of which the principal is the ilio-femoral
Hiatus Hernia or Y-shaped ligament placed in front of the
A displacement of a portion of the stomach joint. A round ligament also unites the head of
through the opening in the diaphragm through the thigh bone to the margin of the
which the oesophagus passes from the chest to acetabulum.
the abdominal cavity (see HERNIA). For hip-joint disease, see under JOINTS, DIS-
EASES OF.
Hiccup
An involuntary spasmodic contraction of the
DIAPHRAGM which produces an indrawing of
Hippocrates
breath during which there is a sudden closure of A famous Greek physician who lived from
the vocal cords. This results in the well-known c.460 to 377 BC and who taught students at
sound and sensation. It is usually of benign the medical school in Cos. Often called the
cause (e.g. indigestion) but may be a symptom father of medicine, he is renowned for drawing
of medullary brain damage, URAEMIA, typhoid up the HIPPOCRATIC OATH, some of which may
fever (see ENTERIC FEVER) or ENCEPHALITIS have been derived from the ancient oath of the
lethargica. There are many folk remedies for Aesclepiads. Apart from his oath, Hippocrates
hiccups, but most cases subside spontaneously. has about 60 other medical works attributed
Prolonged hiccups due to disease may respond to him, forming a corpus which was collected
to treatment with CHLORPROMAZINE or around 250 BC in the famous library of Alex-
HALOPERIDOL.
andria in Egypt. Hippocratic medicine
appealed to reason rather than to rules or to
High Dependency Unit supernatural forces is how the late Roy Porter,
A hospital unit equipped and staffed to nurse the English social historian, summed up its
patients who require a high level of technically ethos in his medical history, The Greatest Benefit
supported care. Patients are usually moved to to Mankind (Harper Collins, 1997). Porter also
such units when they have made satisfactory commended Hippocrates as being patient-
progress in an INTENSIVE THERAPY UNIT (ITU) centred rather than disease-orientated in his
and do not require the one-to-one nursing practice of medicine.
necessary in ITUs. Patients who have under-
gone major surgery are often transferred from Hippocratic Oath
the recovery ward to a high dependency unit An oath once (but no longer) taken by doctors
until they are well enough to be cared for in a on qualification, setting out the moral precepts
standard ward. of their profession and binding them to a code
of behaviour and practice aimed at protecting
Hilum the interests of their patients. The oath is
A term applied to the depression on organs named after HIPPOCRATES (460377 BC), the
such as the lung, kidney, and spleen, at which Greek father of medicine. Almost half of Brit-
the vessels and nerves enter it and around which ish medical students and 98 per cent of Ameri-
the lymphatic glands cluster. The hilum of the can ones make a ceremonial commitment to
lung is also known as its root. assume the responsibilities and obligations of
 334 Hippus

the medical profession, but not by reciting this Histamine

oath. An amine (see AMINES) derived from HISTIDINE.
It is widely distributed in the tissues of plants
Hippus and animals, including humans. It is a powerful
Hippus is a tremor of the iris which produces stimulant of gastric juice, a constrictor of
alternating contraction and dilatation of the smooth muscle including that of the bronchi,
pupil (see EYE). and a dilator of arterioles and capillaries. It is
this last action which is responsible for the
eruption of URTICARIA.
Hirschsprungs Disease
Hirschsprungs disease, or MEGACOLON, is a
rare congenital disorder characterised by great
Histidine
An amino acid from which HISTAMINE is
hypertrophy and dilatation of the colon (see
derived.
INTESTINE). The RECTUM and lower colon have
failed to develop a normal nerve network, thus Histiocytoma
disturbing normal contraction and expansion See DERMATOFIBROMA.
of these structures. Treatment is surgical
H removal of the affected sections, with the Histology
remaining colon being joined to the anus. The study of the minute structure of the tissues
using special staining processes which are com-
Hirsutism bined with electron and light microscopy. The
The growth of hair of the male type and distri- specialty is staffed by medically qualified patho-
bution in women. It is due either to the excess logists (histologists) and scientifically qualified
production of androgens (see ANDROGEN), or to technicians.
undue sensitivity of the hair follicle to normal
female levels of circulating androgens. The lat- Histoplasmosis
ter is called idiopathic hirsutism, because the A disease due to a yeast-like fungus known as
cause is unknown. The increased production of Histoplasma capsulatum. Most cases have been
androgens in the female may come from the reported from the USA. In infants it is charac-
ovary (see OVARIES) and be due to POLYCYSTIC terised by fever, ANAEMIA, enlargement of the
OVARY SYNDROME or an ovarian tumour, or the liver and spleen, and involvement of the lungs
excess androgen may come from the adrenal and gastrointestinal tract. In older children it
cortex (see ADRENAL GLANDS) and be the result may resemble pulmonary tuberculosis, whilst in
of congenital adrenal HYPERPLASIA, an adrenal adults it may be confined to involvement of the
tumour or CUSHINGS SYNDROME. However, skin.
there is a wide range of normality in the distri-
bution of female body hair. It varies with differ- HIV
ent racial groups: the Mediterranean races have Human immunodeficiency virus: the virus that
more body hair than Nordic women, and the is responsible for AIDS (see AIDS/HIV). It is one
Chinese and Japanese have little body hair. It is of the family of human T-cell lymphocy-
not abnormal for many women, especially those totrophic viruses, others of which may cause
with dark hair, to have hair apparent on the lymphomas (see LYMPHOMA) in humans.
upper lip, and a few coarse hairs on the chin
and around the nipples are not uncommon. Hives
Extension of the pubic hair towards the umbil- A popular term applied to eruptions of
icus is also frequently found. Dark hair is much URTICARIA.
more apparent than fair hair, and this is why
bleaching is of considerable benefit in the man- HLA System
agement of hirsutism. The major histocompatibility complex, or
The treatment of hirsutism is that of the human leucocyte antigen (HLA) region, con-
primary cause. Idiopathic hirsutism must be sists of genetically determined antigens, situ-
managed by simple measures such as bleaching ated on chromosome 6. Found in most tissues,
the hair and the use of depilatory waxes and though to a differing extent, the four gene loci
creams. Coarse facial hairs can be removed by are known as A, B, C, D, while the individual
electrolysis, although this is time-consuming. alleles at each locus are numbered 1, 2, 3, etc.
Shaving is often the most effective remedy and The number of possible combinations is thus
neither increases the rate of hair growth nor enormous, and the chance of two unrelated
causes the hairs to become coarser. people being identical for HLA is very low.
 Hookworm 335

HLA incompatibility causes the immune the inability of the affected individual to
response, or rejection reaction, that occurs with metabolise, or to utilise properly, one of the
unmatched tissue grafts. Strong associations essential AMINO ACIDS known as methionine.
between HLA and susceptibility to certain dis- The main features of the condition are
eases notably the AUTOIMMUNE DISORDERS abnormality of the lens of the EYE, learning dis-
such as rheumatoid arthritis, insulin-dependent ability, and a tendency to thromboses (blood
diabetes, and thyrotoxicosis have been clots).
described. Certain HLA antigens occur
together more frequently than would be Homograft
expected by chance (linkage disequilibrium), A piece of tissue or an organ, such as a kidney,
and may have a protective effect, conferring transplanted from one animal to another of the
resistance to a disease. (See IMMUNITY.) same species: for example, from person to per-
son. It is also known as an allograft.
Hodgkins Disease
See LYMPHOMA. Homosexuality
Sexual activity with a member of the same sex.
Holistic There has been considerable debate among psy- H
A term used for a method of medical care in chiatrists as to whether homosexuality should
which patients are treated as a whole, and be regarded as a normal sexual variant or as a
which takes into account their physical and psycho-pathological development or deviation.
mental state as well as social background rather Although homosexuality is found in virtually
than just treating the disease alone. every society and culture, there is no society in
which it is the predominant or preferred mode
Homatropine of sexual activity. Various attempts have been
Homatropine is an alkaloid derived from ATRO- made to link homosexuality to hormonal fac-
PINE, which is used to produce dilatation of the tors, particularly lowered TESTOSTERONE levels,
pupil (see EYE) and to paralyse ACCOMMODA- or to find a genetic explanation, but there is no
TION temporarily for the purpose of examining evidence for either. Psychoanalytic theories link
the interior of the eye. It is used in 1 per cent homosexuality to early child-rearing influences,
solution, and its effects last a few hours. in particular the close-binding and intimate
mother.
Homeopathy The number of homosexual men and women
A system of medicine founded by Hahnemann in the UK is unknown. Re-analysis of the Kin-
at the end of the 18th century. It is based upon sey report suggests that only 3 per cent of adult
the theory that diseases are curable by those men have exclusively homosexual leanings and
drugs which produce effects on the body similar a further 3 per cent have extensive homosexual
to symptoms caused by the disease (similia and heterosexual experience. Homosexuality
similibus curantur). In administering drugs, the among women (lesbianism) seems to be less
theory is also held that their effect is increased common. Some homosexual men have high
by giving them in minute doses obtained by rates of sexual activity and multiple partners
substantially diluting them. and, as with heterosexual men and women, this
increases the risk of acquiring sexually transmit-
Homeostasis ted diseases, unless appropriate precautionary
The normal physiological process which measures are taken for example, the use of
ensures that the bodys internal systems, such as condoms for penetrative sex, whether vaginal or
its metabolism, blood pressure and body tem- anal. It was in homosexual males that the virus
perature, maintain an equilibrium whatever the responsible for AIDS (see AIDS/HIV) was first
conditions of the outside environment. For identified, but the infection now occurs in both
example, the body temperature remains at sexes.
around 37 C (98.4 F) in a cold or a hot
climate. Homozygous
An individual having identical members of the
Homocysteine pair of genes coding for a given characteristic
An intermediate product in the bodys synthesis (see GENES).
of the amino acid CYSTEINE.
Hookworm
Homocystinuria See ANCYLOSTOMIASIS.
Homocystinuria is a congenital disease due to
 336 Hormone Replacement Therapy (HRT)

Hormone Replacement Therapy nose and throat; neurology, etc.). In addition

(HRT) there are teaching hospitals which have the dual
See under MENOPAUSE. function of patient care and the education of
medical staff. (See NATIONAL HEALTH SERVICE
Hormones (NHS).)
These are chemical messengers that are dis- In the UK all patients are entitled to hospital
persed by the blood and act on target organs to care provided by their NHS trust when referred
produce effects distant from their point of by their GENERAL PRACTITIONER (GP) or admit-
release. The main organs involved in hormone ted via the Accident & Emergency department.
production are the PITUITARY GLAND, PAN- (In exceptional cases, patients with severe men-
CREAS, ovary (see OVARIES), testis (see TES- tal illness can be compulsorily admitted by the
TICLE), THYROID GLAND, and ADRENAL authorities.) Admission will depend on clinical
GLANDS. The release of many hormones is, priority, as demand commonly exceeds supply
ultimately, under the control of the central of beds in some localities. Private hospital care
nervous system via a series of inhibiting and is available under the care of a consultant of
releasing factors from the HYPOTHALAMUS. choice, provided that the patient is covered by
H Hormones are involved in maintaining homeo- appropriate private medical insurance or can
stasis: for example, insulin regulates the con- pay direct the substantial hospital and medical
centration of glucose in the blood. They also fees.
participate in growth and maturation: for The future development of hospital medi-
example, growth hormone promotes growth cine is controversial, but the long-term future
and helps to regulate fat, carbohydrate, and may well see many fewer, much better
protein metabolism; and the sex hormones equipped, highly specialised hospitals for
promote sexual maturation and reproduction. patients requiring high-technology-based
(See also ENDOCRINE GLANDS.) treatments. These might be backed up with a
range of smaller general (or halfway) hospitals
Horners Syndrome caring for patients with less demanding clinical
This is the description given to a combination needs who nevertheless require some bed-based
of changes resulting from paralysis of the sym- care. Many more patients requiring routine
pathetic nerve in the neck. They are: a small specialist treatment will be treated as day
pupil; a drooping upper lid; and an apparently patients than is the case now, and there will (or
(though not actually) sunken eye. should) be much greater emphasis (with
appropriate resources) on PREVENTIVE
Horseshoe Kidney MEDICINE.
See KIDNEYS, DISEASES OF. Britain is experimenting with a prototype
virtual hospital. The project will target hos-
Hospice pital patients who need to remain under the
A hospital that cares only for the terminally ill care of specialists but whose condition can be
and dying. The emphasis is on providing qual- managed at home. Suitable NHS patients will
ity of life, and special care is taken in providing be provided with monitoring equipment that
pain relief by whichever methods are deemed enables them, for example, to read their own
best suited to the persons needs. Hospice care blood pressure, lung and heart functions, with
in the United Kingdom has been greatly the results transferred electronically to the office
developed, in particular with the leadership of of relevant specialists who will prescribe and
Dr (Dame) Cicely Saunders. Many hospices are monitor treatment.
funded by charitable funds and their activities
supported by voluntary workers. Hospital-Acquired Infection
An infection acquired by a patient while in
Hospital hospital. Because of the high level of antibiotic
An institution providing treatment for sick and use in hospitals, some bacteria become resistant
injured persons. This may be done on an inpa- for example, METHICILLIN-RESISTANT
tient or outpatient basis. A hospital provides STAPHYLOCOCCUS AUREUS (MRSA). This makes
investigative and therapeutic services which are hospital-acquired infections potentially dan-
not available on a domiciliary basis. gerous and sometimes life-threatening, and is
Hospitals are broadly divided into general one of the developments that is prompting
hospitals (available in each district in the calls for greater care in the prescribing of anti-
United Kingdom) and hospitals specialising in biotics as well as higher standards of
particular ailments (e.g. ophthalmology; ear, cleanliness.
 Human Genome 337

Hospital Chaplaincy Housemaids Knee

A service provided by a religious denomination, An inflammation of the bursa in front of the
primarily aimed at meeting the spiritual and knee-cap, often mistaken for some disease in
religious needs of patients in hospitals. In the the joint itself (see BURSITIS).
UK, NHS hospital trusts employ both full-time
and part-time chaplains, usually representing HRT
the mainline Christian churches (Anglican, Hormone Replacement Therapy see under
Free and Roman Catholic). Their duties vary MENOPAUSE.
but always at the least involve meeting the spe-
cifically religious needs of patients as well as of HSE
relatives and staff who may ask for help. Public See HEALTH AND SAFETY EXECUTIVE (HSE).
services in chapels, the bedside administration
of the Word and Sacraments, and prayers and Human Chorionic
radio services are among chaplains duties. Gonadotrophin
When requested by patients, chaplains also A glycoprotein hormone secreted by the PLA-
liaise with representatives of other world faiths. CENTA in early pregnancy, and stimulating the
Chaplains have a broad responsibility for the CORPUS LUTEUM within the ovary (see OVARIES) H
spiritual health care of all in hospital. They to secrete OESTROGENS, PROGESTERONE, and
share this with other staff members, particularly relaxin. The hormone is essential for the main-
the nursing staff, for whom the chaplains can be tenance of pregnancy up to about 68 weeks of
a resource. Chaplains also train and use volun- gestation. A RADIOIMMUNOASSAY can be used
teers from local churches to help with ward vis- to detect its presence, and pregnancy can be
iting and other chaplaincy duties. Much of the diagnosed as early as six days after conception
time spent with patients takes the form of a by testing for it in the urine. Some tumours also
listening ministry, helping patients to find their secrete human chorionic gonadotrophin, par-
own answers to what is happening to them in ticularly HYDATIDIFORM MOLE, which produces
hospital and in life generally. Spiritual health large amounts.
can be seen as a quest for the right relationships
in four areas with other people; with oneself; Human Fertilisation &
with the world around; and with Life itself. Embryology Act 1990
The religious person subsumes all that in his/ See ASSISTED CONCEPTION.
her relationship to God.
The link between spiritual disease and phys- Human Fertilisation &
ical ill-health is well established; the chaplain Embryology Authority (HFEA)
therefore helps a hospital to provide a HOLISTIC See ASSISTED CONCEPTION.
approach to health care. Chaplains also give
time to the care of staff who face increasing Human Genome
levels of stress at work, making use of support In simple terms, this is the genetic recipe for
groups, counselling, meditation, etc. Chaplains making a human being. GENOME is a combin-
support patients relatives facing a crisis, for ation of the words gene and chromosome,
example, by being with them over the period of and a genome is defined as all the genetic
a death, and by providing regular bereavement material known as deoxyribonucleic acid, or
services for those who have lost babies. Some DNA in a cell. Most genes encode sequences of
chaplains have a particular expertise in ETHICS AMINO ACIDS, the constituents of proteins,
and are members of the various hospital ethics thus initiating and controlling the replication of
committees. A chaplain may have a non- an organism. The identification and character-
management view of the health of the hospital isation of the human genetic puzzle have been a
itself, which can be of use to hospital manage- key bioscience research target. The Human
ment. (See also SPIRITUAL PAIN.) Genome Project was launched in 1990 (and
completed in 2003) to produce a full sequence
Host of the three million base pairs that make up the
An organism on which a parasite lives. human genome.
Carried out as two separate exercises one by
Hour-Glass Stomach a privately funded American team; another by
The term given to the X-ray appearance of a an international joint venture between tax-
stomach which is constricted in its middle part funded American laboratories, a charitably
due either to spasm of the stomach muscle or to funded British one and several other smaller
contraction of scar tissue from a gastric ulcer. research teams from around the world the
 338 Human Immunodeficiency Virus

first results were announced on 26 June 2000. Human Organs Transplants Act
In February 2001 the privately funded Ameri- UK legislation that lays down the framework
can group, known as Celera Genomics, and rules governing organ transplantation. The
announced that it had identified 26,558 genes. UK Transplant Support Service Authority
At the same time the Human Genome Project (UKTSSA), a special health authority set up in
consortium reported that it had identified 1991, is responsible for administering the NHS
31,000. Allowing for margins of error, this Organ Donor Registry and the Act (see APPEN-
gives a figure much lower than the 100,000 or DIX 7: STATUTORY ORGANISATIONS).
more human genes previously forecast by sci-
entists. Interestingly, genes were found to make Humerus
up only 3 per cent of the human genome. The The bone of the upper arm. It has a rounded
remaining 97 per cent of the genome com- head, which helps to form the shoulder-joint,
prises non-coding DNA which, though not and at its lower end presents a wide pulley-like
involved in producing the protein-initiating surface for union with the radius and ulna. Its
genetic activity, does have significant roles in epicondyles form the prominences at the sides
the structure, function and evolution of the of the elbow.
H genome.
One surprise from the Project so far is that Humidification
the genetic differences between humans and The air we breathe must be moist for the effi-
other species seem much smaller than previ- cient working of the lungs (see RESPIRATION).
ously expected. For example, the Celera team Humidification, or moistening of the air, is
found that people have only 300 genes that achieved largely by the NOSE, which acts as an
mice do not have; yet, the common ancestor of air-conditioner, warming, moistening and fil-
mice and men probably lived 100 million years tering the 10,000 litres of air which we inhale
or more in the past. Mice and humans, how- daily in the process of which, incidentally, it
ever, have around twice as many genes as the produces around 15 litres of secretion daily.
humble fruit fly. Humidity is expressed as relative humidity
Cells die out when they become redundant (RH). This is the amount of moisture in the air
during embryonic development: genes also die expressed as a percentage of the maximum pos-
out during evolution, according to evidence sible at that temperature. If the temperature of
from the Genome Project a finding that sup- a room is raised without increasing the mois-
ports the constant evolutionary changes appar- ture content, the RH falls. The average outdoor
ent in living things; the Darwinian concept of RH in Britain is around 7080 per cent; with
survival of the fittest. central heating it may drop to 25 per cent or
Apart from expanding our scientific know- lower. This is why humidification, as it is
ledge, the new information and promise of known, of the air is essential in buildings
much more as the Genome Project continues heated by modern heating systems. The aim
should enhance and expand the use of genetic should be to keep the RH at around 3050 per
engineering in the prevention and cure of dis- cent. In houses this may be achieved quite satis-
ease. Studies are in progress on the gene for a factorily by having a jug or basin of water in
receptor protein in the brain which will shed the room, or some receptacle that can be
light on how the important neurotransmitter attached to the heater. In offices, some more
SEROTONIN in the brain works, and this, for elaborate form of humidifier is necessary.
example, should help the development of better Those suffering from chronic BRONCHITIS are
drugs for the treatment of DEPRESSION. particularly susceptible to dry air, as are those
Another gene has been found that is relevant to individuals with disorders of the EYE because
the development of ASTHMA and yet another the secretions that bathe the eyes and keep
that is involved in the production of amyloid, a them moist are unnaturally dried out. (See also
complex protein which is deposited in excessive VENTILATION.)
amounts in both DOWNS (DOWN) SYNDROME
and ALZHEIMERS DISEASE. Humidifier Fever
A form of ALVEOLITIS caused by contamination
Human Immunodeficiency Virus of the water used to humidify, or moisten, the
See AIDS/HIV. air in air-conditioning plants. The breathing of
the contaminated air results in infection of the
Human Leucocyte Antigen lung, which is characterised by fever, cough,
(HLA) shortness of breath and malaise worse on
See HLA SYSTEM. Monday and tending to improve during the
 Hydradenitis Suppurativa 339

course of the week. (See also LEGIONNAIRES when stained and viewed under the microscope.
DISEASE.) It occurs in a variety of tissues and diseases,
particularly ACUTE RESPIRATORY DISTRESS
Humour SYNDROME (ARDS), hyaline degeneration of
An archaic term once used for a theory regard- arterioles, and alcoholic liver disease.
ing the causation of disease as due to an
improper mixture in the body of blood, bile, Hyaline Membrane Disease
phlegm and black bile. The term remains in A form of ACUTE RESPIRATORY DISTRESS SYN-
describing some body fluids, such as the aque- DROME (ARDS) found in premature infants and
ous and vitreous humours of the EYE. some of those born by CAESAREAN SECTION,
characterised by the onset of difficulty in
Hunger breathing a few hours after birth. Most require
A craving for food or other substance necessary extra oxygen and many need mechanical venti-
to bodily activity. Hunger for food is supposed lation for a few days or even weeks. Recovery is
to be directly produced by strong contractions the rule, although the most severely affected
of the stomach which occur when it is empty, or may die or suffer damage from oxygen lack. In
nearly so. (See also THIRST.) this condition the ALVEOLITIS and the finer H
Air hunger is an instinctive craving for oxy- BRONCHIOLES of the lungs are lined with a
gen resulting in breathlessness, either when a dense membrane. The cause of the condition is
person ascends to great heights where the pres- a deficiency of SURFACTANT in the lung pas-
sure of air is low, or in some diseases such as sages which adversely affects gas exchanges in
pneumonia and DIABETES MELLITUS which the alveoli.
affect the bodys METABOLISM and therefore its Treatment includes the full gamut of neo-
need for oxygen an essential constituent in natal intensive care, as well as specific therapy
this process. with PULMONARY SURFACTANT.

Huntingtons Chorea Hyaluronidase

A hereditary disease characterised by involun- Hyaluronidase is an ENZYME which hydrolyses
tary movements and DEMENTIA. Each child of a hyaluronic acid. The latter is a gel-like sub-
parent with the disease has a 50:50 chance of stance which is widely distributed throughout
developing it. Onset is most common between the body and which helps to bind together the
the ages of 35 and 45, but 10 per cent of cases tissue cells and also acts as a lubricant in joints.
occur under the age of 20. Some patients show By virtue of its action in hydrolysing hyaluronic
more severe mental disturbance; others more acid, hyaluronidase is now used in subcutane-
severe disturbances of movement; but in all it ous injections of fluid as it facilitates the spread
pursues an inexorable downward course over a of the injected fluid and therefore its
period of 1020 years to a terminal state of absorption.
physical and mental helplessness. It is estimated
that there are around 6,000 cases in Britain. Hydatid
The defective gene (located on chromosome A cyst produced by the growth of immature
no. 4) has now been identified and GENETIC forms of a tapeworm. (See TAENIASIS.)
SCREENING is possible for those at risk. People
with Huntingtons chorea and their relatives Hydatidiform Mole
can obtain help and guidance from Hunting- A rare complication of pregnancy, in which
tons Disease Association. there is tremendous proliferation of the epi-
thelium of the chorion (the outer of the two
Hurlers Syndrome fetal membranes). It seldom occurs during a
See GARGOYLISM. first pregnancy. Treatment consists of immedi-
ate evacuation of the womb.
Hutchinsons Teeth
The term applied to the narrowed and notched Hydradenitis Suppurativa
permanent incisor teeth which occur in con- A chronic inflammatory disease of the apocrine
genital SYPHILIS. They are so-named after sweat glands (see PERSPIRATION). It is more
Sir Jonathan Hutchinson (18281913), the common in women in whom it usually occurs
London physician who first described them. in the armpit than in men, in whom it is most
common in the perineum of the drivers of lor-
Hyaline ries and taxis. It occurs in the form of painful,
Tissue material that has a glass-like appearance tender lumps underneath the skin, which burst
 340 Hydrallazine

often in a week or so. Treatment consists of cephalus. The most satisfactory of these utilise
removal by operation. unidirectional valves and shunts (tubes),
whereby the cerebrospinal fluid is bypassed
Hydrallazine from the brain into the right atrium of the heart
A vasodilator hypotensive drug, useful as an or the peritoneal cavity. The shunt may have to
adjunct to other treatment for HYPERTENSION. be left in position indefinitely.

Hydramnios Hydrochloric Acid

A condition characterised by excess of fluid in A colourless, pungent, fuming liquid. Secreted
the amniotic cavity (see AMNION). by the parietal cells in the lining of the stomach,
it aids in the digestion of the food.
Hydrocarbamide
A drug used to treat chronic myeloid leukaemia Hydrochlorothiazide
(see MYELOID; LEUKAEMIA). See THIAZIDES.

Hydrocephalus Hydrocoele
H An abnormal accumulation of CEREBROSPINAL A collection of fluid connected with the testis
FLUID, or CSF, within the skull, as a result of (see TESTICLE) or spermatic cord. When there is
one or more of three main causes: (i) excessive no obvious cause, it is classified as primary:
CSF production; (ii) defective CSF absorption; such hydrocoeles are usually large and tense,
(iii) blockage of the circulation of CSF. Such and are commonly found in middle-aged and
disturbances in the circulation of the fluid may younger men, presenting as a large, painless
be due to congenital reasons (most commonly scrotal swelling. Congenital hydrocoeles may
associated with SPINA BIFIDA), to MENINGITIS, occur in infants, when they are often associated
or to a tumour. with a hernial sac (see HERNIA). Hydrocoele of
the cord is rare. Secondary hydrocoele is gener-
Symptoms In children, the chief symptoms ally smaller and lax; it is usually secondary to
observed are the gradual increase in size of the a tumour or inflammation of the underlying
upper part of the head, out of all proportion to testis or epididymis.
the face or the rest of the body. The head is
globular, with a wide anterior FONTANELLE and Treatment Congenital hydrocoeles usually
separation of the bones at the sutures. The veins disappear spontaneously and may be safely
in the scalp are prominent, and there is a watched; surgery is only indicated when there is
crackpot note on percussion. The normal a hernia, or if the condition persists after the
infants head should not grow more than 25 first year. Hydrocoeles in adults should be
cm (1 inch) in each of the first two months of tapped and the testis palpated to exclude pri-
life, and much more slowly subsequently; mary lesions. Primary hydrocoeles may be
growth beyond this rate should arouse suspi- managed by intermittent tapping, or, prefer-
cions of hydrocephalus, so medical profes- ably, by surgical removal. Secondary hydro-
sionals caring for infants use centile charts for coeles require treatment of the underlying
this purpose. condition.
The cerebral ventricles are widely distended,
and the convolutions of the brain flattened, Hydrocortisone
while occasionally the fluid escapes into the cav- Hydrocortisone has the chemical formula, 17-
ity of the cranium, which it fills, pressing down hydroxycorticosterone. It is closely allied to
the brain to the base of the skull. As a con- CORTISONE both in its structure (cortisone is an
sequence of such changes, the functions of the oxidation product of hydrocortisone) and in its
brain are interfered with, and in general the action. Available in tablet, topical or injection
mental condition of the patient is impaired. form, hydrocortisone is used in adrenocortical
Untreated, the child is dull and listless, irritable insufficiency, for the suppression of local and
and sometimes suffers from severe mental sub- systemic inflammatory and allergic disorders,
normality. The special senses become affected and in the treatment of shock. Its mineralo-
as the disease advances, especially vision, and corticoid effects control of salt and water
sight is often lost, as is also hearing. Towards the balance mean that the drug should not be
end, paralysis is apt to occur. used long term except as replacement therapy
in the treatment of ADDISONS DISEASE or
Treatment Numerous ingenious operations following adrenalectomy when hydrocortisone
have been devised for the treatment of hydro- should be given with the mineral corticoid
 Hyperbaric 341

fludrocortisone(see ADRENAL GLANDS; Hymen

CORTICOSTEROIDS). The thin membranous fold partially closing the
lower end of the virginal VAGINA. If the opening
Hydrogen Peroxide is small, the hymen will tear at the time of first
A thick colourless liquid with the formula intercourse, usually with a little bleeding.
H2O2 (water is H2O, possessing only one oxy-
gen atom in its molecule). Available in solution Hyoid
with water and as a cream, it is readily reduced A U-shaped bone at the root of the tongue. The
to water giving up oxygen in the process, hyoid can be felt from the front of the neck,
which causes the characteristic frothing seen lying about 25 cm above the prominence of the
when used. H2O2 has antiseptic and deodoris- thyroid cartilage.
ing properties; thus it is used as a mouthwash,
to clean wounds and ulcers, and occasionally to Hyoscine
disinfect body cavities at operation. It is also a Also called scopalamine, this is an alkaloid (see
bleach. ALKALOIDS) obtained from the plant henbane
(hyoscyamus). It is an ANTICHOLINERGIC drug
Hydromorphone Hydrochloride sometimes used as a premedicant in patients H
A recently introduced opioid analgesic drug undergoing ANAESTHESIA for its sedative and
used to relieve severe pain in cancer. A con- antiemetic effects and for its ability to reduce
trolled drug, it is taken in capsule form or the saliva production. It may cause confusion in the
powder may be sprinkled over soft food. elderly.

Hydronephrosis Hyper-
See KIDNEYS, DISEASES OF. Prefix denoting abnormally increased or
excessive.
Hydrophobia
Another name for RABIES. Hyperactivity
A pattern of behaviour, usually in children,
Hydrops Fetalis characterised by inability to concentrate,
See HAEMOLYTIC DISEASE OF THE NEWBORN. accompanied by overactivity. (See also ATTEN-
TION DEFICIT DISORDER (HYPERACTIVITY
Hydrotherapy SYNDROME).)
Treatment using water in the form of baths,
douches, etc. Hyperacusis
Hyperacusis means an abnormally acute sense
Hydrothorax of hearing.
A collection of fluid in the pleural cavities of the
lungs. Hyperaemia
Congestion or presence of an excessive amount
Hydroxocobalamin of blood in a body part.
Hydroxocobalamin, or vitamin B12, has now
replaced CYANOCOBALAMIN in the treatment of Hyperaesthesia
pernicious ANAEMIA. It has the practical advan- Oversensitivity of a part of the body as found,
tage that fewer injections are required than in for example, in certain neurological diseases
the case of cyanocobalamin. Like cyanocobal- such as HERPES ZOSTER or shingles. (See also
amin, it belongs to the group of substances TOUCH.)
known as cobalamins which have an ENZYME
action in practically every metabolic system in Hyperalgesia
the body and are essential for normal growth Excessive sensitivity to PAIN; see also TOUCH.
and nutrition. (See APPENDIX 5: VITAMINS.)
Hyperbaric
Hygiene A pressure that is greater than that of the stand-
The science of health and the study of ways of ard atmosphere at sea level (1,013 millibars).
its preservation, particularly by widespread Hyperbaric oxygenation is a procedure in
education and promotion of cleanliness. Espe- which the patient is exposed to high-pressure
cially valuable in developing countries, where it oxygen. The technique is used for the treat-
plays a vital role in helping to limit the spread ment of people suffering from CARBON MON-
of infectious diseases. OXIDE (CO) poisoning, compressed-air illness,
 342 Hypercalcaemia

gas GANGRENE and serious breathing disorders. Hypercholesterolaemia

Occasionally it is used for patients undergoing See CHOLESTEROL; HYPERLIPIDAEMIA.
cardiac surgery.
Hyperemesis Gravidarum
Hypercalcaemia A rare condition (less than 02 per cent) of
A state in which the PLASMA calcium concentra- pregnancy, in which there is severe vomiting. If
tion is significantly raised. The most important untreated it can result in severe dehydration,
causes are HYPERPARATHYROIDISM, malignant ketoacidosis (an excess of KETONE acids) and
bone disease and other (non-metastatic) can- liver damage. More common in multiple preg-
cers, and chronic renal failure. Less common nancy, it may recur in subsequent pregnancies.
causes include SARCOIDOSIS, MYELOMATOSIS,
vitamin D overdosage (see APPENDIX 5: VIT- Hyperglycaemia
AMINS), hyperthyroidism (see THYROID GLAND,
An excess of sugar in the blood that may occur
DISEASES OF), and immobilisation.
in various diseases, typically in DIABETES MEL-
LITUS. The normal blood glucose level in the
fasting state is between 3.5 and 5.5 mmol/1
Signs and symptoms A general malaise and blood (see APPENDIX 6: MEASUREMENTS IN
H depression are common, with generalised mus- MEDICINE); four or five times that amount is
cular weakness, anorexia and vomiting. Dis-
found in diabetes, owing to insufficient insulin
turbed renal function causes increased urine
in the blood, possibly accompanied by an exces-
output and thirst, with calcium deposits even-
sive carbohydrate intake. Untreated, it may lead
tually leading to renal stones. Primary bone dis-
to diabetic coma.
ease may cause pain and weakness, with an
increased incidence of fractures, and there may Hyperidrosis
be gritty deposits of calcium in the eyes. Severe Excessive sweating (see PERSPIRATION).
hypercalcaemia produces ANURIA, with confu-
sion and COMA leading to death. Hyperkalaemia
A concentration of POTASSIUM in the PLASMA
Treatment The patient should be re- that is above the normal range. It is often
hydrated and a diuretic (see DIURETICS) given. caused by renal failure or by excessive intake of
Attention should then be focused on the potassium perhaps in a drug and may cause
underlying cause usually a parathyroid aden- cardiac dysrhythmia (abnormal rhythm of the
oma or bone tumour and surgical removal heart).
should produce complete clinical cure, pro-
vided that advanced renal disease is not already Hyperkeratosis
present. Thickening of the horny (outer) layer of skin,
affecting the palms of the hands and soles of the
Hypercalciuria feet. The disorder may be inherited.
An abnormally large amount of calcium in the
urine. It is the most common single cause of
Hyperkinetic Syndrome
See HYPERACTIVITY.
stones in the KIDNEYS in Britain. (See
HYPERCALCAEMIA.)
Hyperlipidaemia
An excess of fat in the blood, characterising a
Hypercapnia group of metabolic disorders. The two most
An abnormal increase in the amount of carbon important fats circulating in the blood are
dioxide in the blood or in the lungs (see BLOOD CHOLESTEROL and TRIGLYCERIDE. Raised
GASES). It may be caused by a reduced respira- blood levels of cholesterol predispose to
tory rate or effort, diseases of the chest wall and ATHEROMA and coronary artery disease (see
lung (affecting breathing), and cyanotic heart HEART, DISEASES OF); raised triglycerides pre-
disease. dispose to pancreatitis (see PANCREAS, DIS-
ORDERS OF). Six types of hyperlipidaemia have
Hyperchlorhydria been identified, and diagnosis of the different
Excessive production of hydrochloric acid in types depends upon blood tests to discover lipid
the stomach. It is a characteristic finding in cer- levels. Some of the hyperlipidaemias are famil-
tain forms of DYSPEPSIA, particularly that ial, and some are secondary to other diseases
associated with a duodenal ulcer, and causes such as hypothyroidism (see THYROID GLAND,
HEARTBURN and WATERBRASH. (See also DUO- DISEASES OF), DIABETES MELLITUS, nephrotic
DENAL ULCER; STOMACH, DISEASES OF.) syndrome and alcoholism.
 Hypertension 343

Treatment There is evidence that therapy among the presenting symptoms, but the
which lowers the lipid concentration reduces tumour may be symptomless for many years.
the progression of premature atheroma, particu- Surgical removal is the initial treatment; hyper-
larly in those who suffer from the familial dis- nephromas are fairly insensitive to CYTOTOXIC
order. Treatment should include appropriate drugs and RADIOTHERAPY although hormone
diets, usually food that is low in cholesterol and treatment may help and are prone to spread
saturated fats. There are a number of drugs via the bloodstream, for example, to the lungs.
available for lowering the lipid content of the
plasma, but these should be reserved for Hyperparathyroidism
patients in whom severe hyperlipidaemia is Increased activity of the PARATHYROID gland.
inadequately controlled by weight reduction. Parathyroid hormone increases SERUM calcium.
Anion-exchange resins clofibrate, bezafibrate Hyperparathyroidism may be primary (due to
and gemfibrozil, for example and statins such an ADENOMA or HYPERPLASIA of the gland),
as atorvastatin and simvastatin, as well as nico- secondary (in response to HYPOCALCAEMIA) or
tinic acid, all lower plasma cholesterol and tertiary (when secondary hyperparathyroidism
plasma triglyceride concentration through their causes the development of an autonomous
effect on reducing the hepatic production of adenoma). H
lipoproteins. Cholestyramine and colestipol,
both of which are anion-exchange resins, bind Hyperpituitarism
bile salts in the gut and so decrease the absorp- Overactivity of the anterior lobe of the PITUIT-
tion of the cholesterol that these bile salts con- ARY GLAND, causing ACROMEGALY
tain hence lowering plasma cholesterol con- (GIGANTISM).
centrations. Probucol lowers plasma cholesterol
concentrations by increasing the metabolism of Hyperplasia
low-density lipoproteins. Hyperplasia means an abnormal increase in the
The statins (atorvastatin, cerivastatin, fluvas- number of cells in a tissue.
tatin, pravastatin and simvastatin) inhibit an
enzyme involved in synthesising cholesterol, Hyperprolactinaemia
especially in the liver. They are more effective Overproduction of the hormone PROLACTIN,
than anion-exchange resins in lowering LDL usually as a result of a tumour of the PITUITARY
(low-density lipoprotein) cholesterol a form GLAND (prolactinoma).
of low-density cholesterol carried in the blood-
stream, high levels of which are believed to be Hyperpyrexia
the main cause of atheroma. Statins are, how- High FEVER. (See also TEMPERATURE.)
ever, less effective than the clofibrate group in
reducing triglycerides and raising HDL (high- Hypersensitivity
density lipoprotein) cholesterol (high-density An abnormal immunological reaction produced
cholesterol). by some people when re-exposed to antigens
that are innocuous to normal individuals. An
Hypermetropia antigen or allergen is a protein that stimulates
Hypermetropia, or hyperopia, is a term applied an allergic response. This may mean that the
to long-sightedness, in which the eye is too flat next time the person is exposed to that antigen,
from front to back and rays of light are brought there may be a dramatic health- or life-
to a focus behind the retina. (See EYE; VISION.) threatening reaction, such as ANAPHYLAXIS. (See
also ALLERGY; IMMUNITY.)
Hypernatraemia
A SERUM sodium concentration that is above Hypertension
normal. The condition is usually caused by Means high BLOOD PRESSURE (raised pressure
dehydration (either from inadequate intake or of the circulating blood), but since there is a
excessive loss of water); occasionally it may be wide range of normal blood pressure in the
caused by excessive sodium intake, and rarely population, a precise level of pressure above
by a raised level of ALDOSTERONE hormone. which an individual is deemed hypertensive is
arbitrary. (A healthy young adult would be
Hypernephroma expected to have a systolic pressure of around
Now named renal cell carcinoma, this is a 120 mm Hg and a diastolic of 80 mm Hg,
malignant tumour resembling the tissue of the recorded as 120/80.) Hypertension is not a dis-
suprarenal gland and occurring in the KIDNEYS. ease as such but a quantitative deviation from
Fever, loin pain, HAEMATURIA and swelling are the norm. A person with a pressure higher than
 344 Hypertension

the average for his or her age group is usually ondary. Among the causes of secondary hyper-
symptomless although sometimes such people tension are:
may develop headaches. The identification of
people with hypertension is important because
Lifestyle factors such as smoking, alcohol,
stress, excessive dietary salt and obesity.
it is a signal that they will be more likely to have Diseases of the KIDNEYS.
a STROKE or myocardial infarct (coronary Pregnancy (ECLAMPSIA).
thrombosis or heart attack) than someone
whose pressure is in the normal range. Pre-
Various ENDOCRINE disorders for example,
PHAEOCHROMOCYTOMA, CUSHINGS DIS-
ventive steps can then be taken to lessen the EASE, ACROMEGALY, thyrotoxicosis (see under
likelihood of their developing these potentially THYROID GLAND, DISEASES OF).
life-threatening conditions. COARCTATION OF THE AORTA.
Blood pressure is measured using two values.
The systolic pressure the greater of the two
Drugs for example, oestrogen-containing
oral contraceptives (see under CONTRACEP-
represents the pressure when blood is pumped TION), ANABOLIC STEROIDS, CORTICO-
from the left VENTRICLE of the heart into the STEROIDS, NON-STEROIDAL ANTI-
AORTA. The diastolic pressure is the measure- INFLAMMATORY DRUGS (NSAIDS).
H ment when both ventricles relax between beats.
The pressures are measured in millimetres Treatment People with severe hypertension
(mm) of mercury (Hg). Despite the grey area may need prompt admission to hospital for
between normal and raised blood pressure, the urgent investigation and treatment. Those with
World Health Organisation (WHO) has a mild to moderate rise in blood pressure for
defined hypertension as a blood pressure con- which no cause is identifiable should be advised
sistently greater than 160 mm Hg (systolic) and to change their lifestyle: smokers should stop
95 mm Hg (diastolic). Young children have the habit, and those with high alcohol con-
readings well below these, but blood pressure sumption should greatly reduce or stop their
rises with age and a healthy person may well live drinking. Obese people should reduce their
symptom free with a systolic pressure above the food consumption, especially of animal fats,
WHO figure. A useful working definition of and take more exercise. Everyone with hyper-
hypertension is the figure at which the benefits tension should follow a low-salt diet and take
of treating the condition outweigh the risks and regular exercise. Patients should also be taught
costs of the treatment. how to relax, which helps to reduce blood pres-
Between 10 and 20 per cent of the adult sure and, if they have a stressful life, working
population in the UK has hypertension, with patterns should be modified if possible. If these
more men than women affected. Incidence is lifestyle changes do not reduce a persons blood
highest in the middle-aged and elderly. Because pressure sufficiently, drugs to achieve this will
most people with hypertension are symptom- be needed. A wide range of anti-hypertensive
less, the condition is often first identified dur- drugs are available on prescription.
ing a routine medical examination, otherwise a A first-line treatment is one of the THIAZ-
diagnosis is usually made when complications IDES, effective at a low dosage and especially
occur. Many peoples blood pressure rises when useful in the elderly. Beta blockers (see BETA-
they are anxious or after exercise, so if some- ADRENOCEPTOR-BLOCKING DRUGS), such as
ones pressure is above normal at the first test- oxprenolol, acebutol or atenolol, are also
ing, it should be taken again after, say, 10 min- first-line treatments. ACE inhibitors (see
utes rest, by which time the reading should ANGIOTENSIN-CONVERTING ENZYME (ACE)
have settled to the persons regular level. BP INHIBITORS) and CALCIUM-CHANNEL
measurements should then be taken on two BLOCKERS can be used if the first-line choices
subsequent occasions. If the pressure is still are not effective. The drug treatment of hyper-
high, the cause needs to be determined: this is tension is complex, and sometimes various
done using a combination of personal and fam- drugs or combinations of drugs have to be tried
ily histories (hypertension can run in families), to find what regimen is effective and suits the
a physical examination and investigations, patient. Mild to moderate hypertension can
including an ECG and blood tests for renal usually be treated in general practice, but
disease. patients who do not respond or have complica-
Over 90 per cent of hypertensive people have tions will normally require specialist advice.
no immediately identifiable cause for their con- Patients on anti-hypertensive treatments
dition. They are described as having essential require regular monitoring, and, as treatment
hypertension. In those patients with an identifi- may be necessary for several years, particular
able cause, the hypertension is described as sec- attention should be paid to identifying side-
 Hyperventilation 345

effects. Nevertheless, effective treatment of causing PAPILLOEDEMA. Haemorrhages may

hypertension does enable affected individuals to occur in the brain, usually in the area of the
live longer and more comfortable lives than BASAL GANGLIA. Neurological symptoms can
would otherwise be the case. Older people with usually be treated effectively by controlling the
moderately raised blood pressure are often able patients hypertension.
to live with the condition, and treatment with
anti-hypertensive drugs may produce symp- Hyperthermia
toms of HYPOTENSION. Hyperthermia means abnormally high body
In summary, hypertension is a complex dis- temperature. A rapid rise of temperature to
order, with different patients responding differ- dangerous levels called malignant hyper-
ently to treatment. So the condition sometimes thermia may be precipitated by general
requires careful assessment before the most ANAESTHESIA but the condition is rare
effective therapy for a particular individual is (1:50,000 operations) and is usually inherited.
identified, and continued monitoring of The anaesthetic is stopped and icepacks are
patients with the disorder is advisable. used to cool the patient. Pure oxygen and intra-
venous sodium choride are also administered.
Complications Untreated hypertension may It is also the name given to the treatment of H
eventually result in serious complications. disease by the artificial production of FEVER.
People with high blood pressure have blood This can be achieved by various methods, such
vessels with thickened, less flexible walls, a nar- as radiation heat cabinets boosted with radio
rowed LUMEN and convoluted shape. Some- frequency (RF); immersion in a hot wax bath;
times arteries become rigid. ANEURYSM may heated suits or blankets; techniques using elec-
develop and widespread ATHEROMA (fat tromagnetic waves (e.g. RF, MICROWAVES); and
deposits) is apparent in the arterial linings. Such ULTRASOUND of appropriate frequencies.
changes adversely affect the blood supply to Hyperthermia is sometimes of help as an
body tissues and organs and so damage their adjunct to surgery, CHEMOTHERAPY, or RADIO-
functioning. Patients suffer STROKE (haemor- THERAPY in the treatment of cancer.
rhage from or thrombosis in the arteries of the
BRAIN) and heart attacks (coronary thrombosis Hyperthyroidism
see HEART, DISEASES OF). Those with hyper- Excessive activity of the thyroid gland. (See
tension may suffer damage to the retina of THYROID GLAND, DISEASES OF.)
the EYE and to the OPTIC DISC. Indeed, the
diagnosis of hypertension is sometimes made Hypertonic
during a routine eye test, when the doctor or (1) Referring to one solution which has a
optician notices changes in the retinal arteries greater osmotic pressure (see OSMOSIS) than
or optic disc. Kidney function is often affected, another. Physiologically it is used to describe
with patients excreting protein and excessive solutions which have a greater osmotic pressure
salt in their urine. Occasionally someone with than body fluids.
persistent hypertension may suffer an acceler- (2) Muscles with abnormally increased tone
ation of damage to the blood vessels a condi- (e.g. following a STROKE).
tion described as malignant hypertension, and
one requiring urgent hospital treatment. Hypertrophy
Hypertension is a potentially dangerous dis- The increase in size which takes place in an
ease because it develops into a cycle of self- organ as the result of an increased amount of
perpetuating damage. Faulty blood vessels lead work demanded of it by the bodily economy.
to high blood pressure which in turn aggravates For example, when valvular disease of the heart
the damage in the vessels and thus in the tissues is present, compensation occurs by an increase
and organs they supply with blood; this further in thickness of the heart muscle, and the organ,
raises the affected individuals blood pressure by beating more powerfully, is able to overtake
and the pathological cycle continues. the strain thrown upon it. Similarly, if one kid-
ney is removed, the other hypertrophies or
Hypertensive Encephalopathy grows larger to take over the double workload.
A complication of severe HYPERTENSION, this
serious but uncommon condition is character- Hyperventilation
ised by neurological symptoms which include An abnormally rapid resting respiratory rate (see
transient verbal and visual disturbances, PAR- RESPIRATION). If voluntarily induced, it causes
AESTHESIA, disorientation, fits and sometimes lightheadedness and then unconsciousness by
loss of consciousness. It also affects the eyes, lowering the blood tension of carbon dioxide.
 346 Hypervolaemia

Hyperventilation is a manifestation of chest FLUNITRAZEPAM is a tranquilliser/hypnotic that

and heart diseases which raise carbon dioxide has been misused as a recreational drug.
tension or cause HYPOXIA (e.g. severe CHRONIC
OBSTRUCTIVE PULMONARY DISEASE (COPD) or Hypnotism
PULMONARY OEDEMA). Mechanically venti- The process of producing a state of mind
lated patients may be hyperventilated to lower known as hypnosis. Although recognised for
carbon dioxide tension in order to reduce hundreds of years, the precise nature of this
INTRACRANIAL PRESSURE. (See also process is still poorly understood. One modern
HYPOCAPNIA.) writer has defined hypnosis as a temporary
condition of altered attention, the most striking
Hypervolaemia feature of which is greatly increased suggest-
An increase in the volume of circulating blood ibility. There is no evidence, as has been
above the normal range. claimed, that women can be more easily hypno-
tised than men; in fact, children and young
Hypnotics adults are the more easily hypnotised, with
These are drugs that induce SLEEP. Before a middle-aged people being more resistant.
H hypnotic is prescribed, it is vital to establish Hypnosis is induced by various methods, but
and, where possible, treat the cause of the the basis of all is some rhythmic stimulus
insomnia (see under SLEEP, DISORDERS OF). Hyp- accompanied by the repetition of carefully
notics are most often needed to help an acutely worded suggestions. The most commonly used
distressed patient (for example, following method is to ask the patient to fix his or her eye
bereavement), or in cases of jet lag, or in shift on a given spot, or light, and then to keep on
workers. repeating, in a quiet and soothing voice, that
If required in states of chronic distress, the patients eyes will gradually become tired
whether induced by disease or environment, it and that he or she will want to close them.
is especially important to limit the drugs to a There are various levels of hypnosis, usually
short time to prevent undue reliance on them, classified as light, medium, and deep, and it has
and to prevent the use of hypnotics and seda- been estimated that 10 per cent of people can-
tives from becoming a means of avoiding the not be hypnotised; 35 per cent can be taken
patients real problem. In many cases, such as into light hypnosis; 35 per cent into medium
chronic depression, overwork, and alcohol hypnosis; and 20 per cent into deep hypnosis.
abuse, hypnotics are quite inappropriate; some Hypnosis can be used as a treatment for some
form of counselling and relaxation therapy is psychiatric patients and in some people with
preferable. psychosomatic conditions in which emotional
Hypnotics should always be chosen and pre- or psychological disturbances precipitate phys-
scribed with care, bearing in mind the patients ical disorders such as skin lesions or headaches.
full circumstances. They are generally best Hypnosis may help to relieve pain in childbirth;
avoided in the elderly (confusion is a common asthma may also respond to it. Some people
problem), and in children apart from special may find hypnosis to be of help in overcoming
cases. Barbiturates should not now be used as addictions to smoking, alcohol or gambling.
they tend to be addictive. The most commonly The process has associated risks, and its use in
used hypnotics are the BENZODIAZEPINES such treatment should be by doctors trained in the
as nitrazepam and temazepam; chloral deriva- technique.
tives, while safer for the few children who merit
them, are generally second choice and should Hypo-
be used in the lowest possible dose for the min- A prefix meaning below, under, or less than
imum period. normal: for example, hypotension (low blood
Side-effects include daytime drowsiness pressure) and hypodermic (under the skin).
which may interfere with driving and other
skilled tasks and insomnia following with- Hypocalcaemia
drawal, especially after prolonged use, is a haz- A SERUM concentration of calcium below the
ard. Occasionally benzodiazepines will trigger normal range (between 2.33 and 3.05 mmol of
hostility and aggression. Zolpidem and zopi- calcium per 100 ml of serum). This may cause
clone are two drugs similar to the benzo- TETANY, acutely; chronically it may give rise to
diazepines, indicated for short-term treatment RICKETS, OSTEOMALACIA or osteoporosis (see
of insomnia in the elderly. Adverse effects BONE, DISORDERS OF). It may be caused by
include confusion, incoordination and hypoparathyroidism (see THYROID GLAND, DIS-
unsteadiness, and falls have been reported. EASES OF), vitamin D deficiency (see APPENDIX
 Hypoglycaemic Agents 347

5: VITAMINS), malabsorption, renal failure or largely comprises antibodies (IMMUNO-

acute pancreatitis (see PANCREAS, DISORDERS OF). GLOBULINS) so deficiency of the protein reduces
an individuals natural resistance to infection
Hypocapnia (see IMMUNOLOGY).
A blood tension of carbon dioxide below nor-
mal. It is produced by HYPERVENTILATION Hypogastric
which may be voluntary, mechanical (if the A term means pertaining to the lower middle
patient is on a ventilator) or in response to a part of the abdomen, just above the pubis.
physiological insult such as metabolic acidosis
or brain injury. Hypoglossal Nerve
The 12th cranial nerve, which supplies the
Hypochlorhydria muscles of the tongue, together with some
An insufficient secretion of HYDROCHLORIC others lying near it. This nerve is responsible for
ACID from the digestive cells of the stomach movements required for swallowing and talk-
lining. ing. (See also NERVOUS SYSTEM.)

Hypochondriasis Hypoglycaemia H
Obsession with the bodys functions and a A deficiency of glucose in the blood the nor-
DELUSION of ill health, often severe, such that mal range being 3575 mmol/l (see DIABETES
patients may believe they have a brain tumour MELLITUS). It most commonly occurs in dia-
or incurable insanity. Furthermore, patients betic patients for example, after an excessive
may believe that they have infected others, or dose of INSULIN and heavy exercise, particularly
that their children have inherited the condition. with inadequate or delayed meals. It may also
It is a characteristic feature of DEPRESSION, but occur in non-diabetic people, however: for
may also occur in SCHIZOPHRENIA, when the example, in very cold situations or after periods
delusions may be secondary to bodily HAL- of starvation. Hypoglycaemia is normally indi-
LUCINATIONS, and a sense of subjective change. cated by characteristic warning signs and
Chronic hypochondriasis may be the result of symptoms, particularly if the blood glucose
an abnormal personality development: for concentration is falling rapidly. These include
example, the insecure, bodily-conscious person. anxiety, tremor, sweating, breathlessness, raised
Delusional preoccupations with the body pulse rate, blurred vision and reduced concen-
usually the face may occur, such that the tration, leading in severe cases to
patient is convinced that his or her face is unconsciousness. Symptoms may be relieved by
twisted, or disfigured with acne. taking some sugar, some sweet biscuits or a
sweetened drink. In emergencies, such as when
Treatment Hypochondriacal patients may the patient is comatose (see COMA), an intra-
also develop physical illness, and any new muscular injection of GLUCAGON or intraven-
symptoms must always be carefully evaluated. ous glucose should be given. Early treatment is
In most patients the condition is secondary, and vital, since prolonged hypoglycaemia, by starv-
treatment should be directed to the underlying ing the brain cells of glucose, may lead to
depression or schizophrenia. In the rare cases of irreversible brain damage.
primary hypochondriasis, supportive measures
are the mainstay of treatment. Hypoglycaemic Agents
These oral agents reduce the excessive amounts
Hypodermic of GLUCOSE in the blood (HYPERGLYCAEMIA) in
A term pertaining to the region immediately people with type 2 (INSULIN-resistant) diabetes
under the skin. Thus, a hypodermic injection (see DIABETES MELLITUS). Although the various
means an injection given underneath the skin. drugs act differently, most depend on a supply of
A hypodermic syringe is a small syringe which, endogenous (secreted by the PANCREAS) insulin.
fitted with a fine needle, is used to give such Thus they are of no value in treating patients
injections. with type 1 diabetes (insulin-dependent dia-
betes mellitus (IDDM), in which the pancreas
Hypogammaglobulinaemia produces little or no insulin and the patients
A lower-than-normal amount of the protein condition is stabilised using insulin injections).
GAMMA-GLOBULIN in the blood. The origin The traditional oral hypoglycaemic drugs have
may be genetic several types are inherited or been the sulphonylureas and biguanides; new
an acquired defect (for instance, some lymph- agents are now available for example,
omas cause the condition). Gamma-globulin thiazolidine-diones (insulin-enhancing agents)
 348 Hypoglycaemic Coma

and alpha-glucosidase inhibitors, which delay Sensitivity reactions are very rare, usually
the digestion of CARBOHYDRATE and the occurring in the first six to eight weeks of ther-
absorption of glucose. Hypoglycaemic agents apy. They include transient rashes which rarely
should not be prescribed until diabetic patients progress to erythema multiforme (see under ERY-
have been shown not to respond adequately to THEMA) and exfoliate DERMATITIS, fever and
at least three months restriction of energy and jaundice; chlorpropamide may also occasionally
carbohydrate intake. result in photosensitivity. Rare blood disorders
include THROMBOCYTOPENIA, AGRANULOCY-
Sulphonylureas The main group of hypo- TOSIS and aplastic ANAEMIA.
glycaemic agents, these act on the beta cells to
stimulate insulin release; consequently they are Biguanides Metformin, the only available
effective only when there is some residual pan- member of this group, acts by reducing GLU-
creatic beta-cell activity (see INSULIN). They also CONEOGENESIS and by increasing peripheral
act on peripheral tissues to increase sensitivity, utilisation of glucose. It can act only if there is
although this is less important. All sulphonylu- some residual insulin activity, hence it is only of
reas may lead to HYPOGLYCAEMIA four hours or value in the treatment of non-insulin depend-
H more after food, but this is relatively uncom- ent (type 2) diabetics. It may be used alone or
mon, and usually an indication of overdose. with a sulphonylurea, and is indicated when
There are several different sulphonylureas; strict dieting and sulphonylurea treatment have
apart from some differences in their duration or failed to control the diabetes. It is particularly
action (and hence in their suitability for indi- valuable in overweight patients, in whom it
vidual patients) there is little difference in their may be used first. Metformin has several advan-
effectiveness. Only chlorpropamide has appre- tages: hypoglycaemia is not usually a problem;
ciably more side-effects mainly because of its weight gain is uncommon; and plasma insulin
prolonged duration of action and consequent levels are lowered. Gastrointestinal side-effects
risk of hypoglycaemia. There is also the are initially common and persistent in some
common and unpleasant chlorpropamide/ patients, especially when high doses are being
alcohol-flush phenomenon when the patient taken. Lactic acidosis is a rarely seen hazard
takes alcohol. Selection of an individual occurring in patients with renal impairment, in
sulphonylurea depends on the patients age and whom metformin should not be used.
renal function, and often just on personal pref-
erence. Elderly patients are particularly prone to Other antidiabetics Acarbose is an inhibi-
the risks of hypoglycaemia when long-acting tor of intestinal alpha glucosidases (enzymes
drugs are used. In these patients chlorpro- that process GLUCOSIDES), delaying the diges-
pamide, and preferably glibenclamide, should tion of starch and sucrose, and hence the
be avoided and replaced by others such as increase in blood glucose concentrations after a
gliclazide or tolbutamide. meal containing carbohydrate. It has been
These drugs may cause weight gain and are introduced for the treatment of type 2 patients
indicated only if poor control persists despite inadequately controlled by diet or diet with oral
adequate attempts at dieting. They should not hypoglycaemics.
be used during breast feeding, and caution is Guar gum, if taken in adequate doses, acts by
necessary in the elderly and in those with renal delaying carbohydrate absorption, and there-
or hepatic insufficiency. They should also be fore reducing the postprandial blood glucose
avoided in porphyria (see PORPHYRIAS). During levels. It is also used to relieve symptoms of the
surgery and intercurrent illness (such as myo- DUMPING SYNDROME.
cardial infarction, COMA, infection and
trauma), insulin therapy should be temporarily Hypoglycaemic Coma
substituted. Insulin is generally used during Hypoglycaemia or low blood sugar occurs when
pregnancy and should be used in the presence a patient with DIABETES MELLITUS suffers an
of ketoacidosis. imbalance between carbohydrate/glucose intake
and INSULIN dosage. If there is more insulin
Side-effects Chiefly gastrointestinal disturb- than is needed to help metabolise the available
ances and headache; these are generally mild carbohydrate, it causes a range of symptoms
and infrequent. After drinking alcohol, chlo- such as sweating, trembling, pounding heart-
rpropamide may cause facial flushing. It also beat, anxiety, hunger, nausea, tiredness and
may enhance the action of antidiuretic hor- headache. If the situation is not quickly rem-
mone (see VASOPRESSIN), very rarely causing edied by taking oral sugar or, if severe, giving
HYPONATRAEMIA. glucose by injection the patient may become
 Hypoprothrombinaemia 349

confused, drowsy and uncoordinated, finally tions intravenously), excessive water retention
lapsing into a COMA. Hypoglycaemia is (inappropriate secretion of antidiuretic hor-
infrequent in people whose diabetes is con- mone), excessive sodium loss, and, rarely, by
trolled with diet and oral HYPOGLYCAEMIC inadequate salt intake.
AGENTS.
Treatment of acute hypoglycaemia depends Hypoparathyroidism
upon the severity of the condition. Oral carbo- Underactivity of the parathyroid glands (see
hydrate, such as a sugary drink or chocolate, under ENDOCRINE GLANDS). Thus there is a lack
may be effective if the patient is conscious of parathyroid hormone resulting in HYPOCAL-
enough to swallow; if not, glucose or GLUCA- CAEMIA. It may be caused by inadvertent
GON by injection will be required. Comatose removal of the glands when the thyroid gland is
patients who recover after an injection should surgically removed, or by failure of the glands
then be given oral carbohydrates. An occasional because of autoimmune disease.
but dangerous complication of coma is cerebral
oedema (see BRAIN, DISEASES OF Cerebral Hypophysectomy
oedema), and this should be considered if coma Surgical excision of the PITUITARY GLAND. This
persists. Emergency treatment in hospital is can be done by opening the skull, by inserting
very low-temperature needles (CRYOSURGERY) H
then needed. When the patient has recovered,
management of his or her diabetes should be into the gland, or by inserting needles of radio-
assessed in order to prevent further hypo- active YTTRIUM-90.
glycaemic attacks.
Hypophysis
Hypogonadism Another name for the PITUITARY GLAND.
A condition characterised by underactivity of
the testes (see TESTICLE) or OVARIES the
Hypopiesis
The condition, or state, characterised by HYPO-
gonads. The condition may be caused by a gen-
TENSION, or abnormally low blood pressure.
etically based disorder resulting in an
abnormally functioning gonad (primary Hypopituitarism
hypogonadism) or by a malfunctioning PITUIT- Underactivity of the PITUITARY GLAND. It can
ARY GLAND that fails to produce an adequate
cause dwarfism, delayed puberty, impotence,
amount of gonadotrophin hormone (see GON- infertility, AMENORRHOEA, hypothyroidism
ADOTROPHINS) secondary hypogonadism.
(see THYROID GLAND, DISEASES OF), and hypo-
Those affected may fail to develop adequately adrenalism. Causes include tumours, irradi-
the secondary characteristics of their sex: males ation of the gland, SARCOIDOSIS, and necrosis
will have delayed puberty, erectile impotence associated with post-partum haemorrhage
and infertility and also develop GYNAECO- (Sheehans syndrome).
MASTIA; females also have delayed puberty,
infertility, and sometimes HIRSUTISM. Hypoplasia
Excessive smallness of an organ or part, arising
Hypokalaemia from imperfect development.
An abnormally low concentration of potassium
in the blood. Hypoproteinaemia
A fall in the amount of PROTEIN in the blood.
Hypomania This may be caused by malnutrition, loss of
Hypomania is a modest manifestation of mania protein from kidney disorders, or faulty pro-
(see under MENTAL ILLNESS). The individual is duction of protein which occurs in some liver
elated to an extent that he or she may make disorders. Hypoproteinaemia causes OEDEMA
unwise decisions, and social behaviour may because fluid accumulates in the tissues as a
become animated and uninhibited. To the cas- consequence of the metabolic abnormalities.
ual observer individuals may, however, seem Patients resistance to infections is also
normal. Treatment is advisable to prevent them impaired.
from harming their own or their familys inter-
ests. Treatment is as for mania. Hypoprothrombinaemia
A deficiency of PROTHROMBIN (clotting factor)
Hyponatraemia in the blood. As a result the affected indi-
A SERUM concentration of sodium below the vidual tends to bleed more easily. The defect
normal range. It may be produced by dilution may be inherited or be the consequence of
of blood (giving large volumes of salt-poor solu- liver disease or a deficiency in vitamin K.
 350 Hypospadias

Anticoagulant therapy will also cause a fall in get out of a bath quickly. Someone who faints
prothrombin levels. as a result of a hypotensive incident should be
laid down for a few minutes to allow the circu-
Hypospadias lation to return to normal. Hypotension result-
A developmental abnormality in the male, in ing from burns, blood loss, heart attack or
which the URETHRA opens on the undersurface adrenal failure (shock) requires medical atten-
of the penis or in the PERINEUM. The condition tion for the causative condition.
is treatable with surgery, but several operations
over a period of years may be required to ensure Hypothalamus
normal urinary and sexual functions. That part of the fore-brain situated beneath and
linked with the THALAMUS on each side and
Hypostasis forming the floor of the third ventricle (see
The term applied to the condition in which BRAIN). Also linked to the PITUITARY GLAND
blood accumulates in a dependent part of the beneath it, the hypothalamus contains collec-
body as a result of poor circulation. Congestion tions of nerve cells believed to form the control-
of the base of the lungs in old people from this ling centres of (1) the sympathetic and (2) the
H cause, and infection, is called hypostatic parasympathetic nervous systems (see under NER-
PNEUMONIA. VOUS SYSTEM). The hypothalamus is the ner-
vous centre for primitive physical and emo-
Hypotension tional behaviour. It contains nerve centres for
Low blood pressure (see HYPERTENSION for the regulation of certain vital processes: the
raised blood pressure). Some healthy indi- metabolism of fat, carbohydrate and water;
viduals with a normal cardiovascular system sleep; body temperature and sexual functions.
have a permanently low arterial blood pressure
for their age. What blood-pressure reading con- Hypothermia
stitutes hypotension is arguable, but a healthy A core body temperature of less than 35 C. As
young person with figures below 100 mm Hg the temperature of the body falls, there is
systolic and 65 mm Hg diastolic could be increasing dysfunction of all the organs, par-
described as hypotensive. For a healthy 60 year ticularly the central nervous and cardiovascular
old, comparative figures might be 120/80. The systems. The patient becomes listless and con-
most common type of hypotension is called fused, with onset of unconsciousness between
postural, with symptoms occurring when a per- 3328 C. Cardiac output at first rises with
son suddenly stands up, particularly after a shivering but then falls progressively, as do the
period of rest or a hot bath. It results from the oxygen requirements of the tissues. Below 17
muscular tone of blood vessels becoming 26 C, cardiac output is insufficient even to
relaxed and being unable to respond quickly supply this reduced demand for oxygen by the
enough to the changing posture, the con- tissues. The heart is susceptible to spontaneous
sequence being a temporary shortage of arterial ventricular FIBRILLATION below 28 C. Metab-
blood to the brain and organs in the chest. olism is disturbed and the concentration of
Symptoms of dizziness, occasionally fainting, blood GLUCOSE and POTASSIUM rises as the
and nausea occur. Older people are especially temperature falls. Cooling of the kidneys pro-
vulnerable and may fall as a result of the sudden duces a DIURESIS and further fluid loss from the
hypotension. Some drugs anti-hypertensives circulation to the tissues causes HYPOVOLAEMIA.
and antidepressant ones cause hypotension. Severe hypothermia is sometimes compli-
People with DIABETES MELLITUS occasionally cated by gastric erosions and haemorrhage, as
develop hypotension because of nerve damage well as pancreatitis (see PANCREAS, DISORDERS
that affects the reflex impulses controlling OF). Infants and the elderly are less efficient at
blood pressure. Any severe injury or burn that regulating temperature and conserving heat
results in serious loss of blood or body fluid will than other age groups, and are therefore more at
cause hypotension and SHOCK. Myocardial risk from accidental hypothermia during cold
infarction (see HEART, DISEASES OF) or failure of weather if their accommodation is not warm
the ADRENAL GLANDS can cause hypotension enough. Approximately half a million elderly
and shock. A severe emotional event that causes people are at risk in Britain each winter from
shock may also result in hypotension and hypothermia. The other major cause of acci-
fainting. dental hypothermia is near-drowning in icy
Hypotension in healthy people does not water. Deliberate hypothermia is sometimes
require treatment, although affected individuals used to reduce metabolic rate so that prolonged
should be advised not to stand up suddenly or periods of cardiac arrest may occur without
 Hysterotomy 351

tissue HYPOXIA developing. This technique is it will cause organ damage and death, as cellular
used for some cardiac and neurosurgical oper- function is dependent on oxygen. (See also
ations and is produced by immersion of the HYPOXAEMIA.)
anaesthetised patient in iced water or by cooling
an extracorporeal circulation. Hysterectomy
Treatment of hypothermia is by warming the Surgical removal of the UTERUS. Hystero-
patient and treating any complications that oophorectomy is the term applied to removal of
arise. Passive warming is usual, with conserva- the uterus and OVARIES. (See also UTERUS, DIS-
tion of the patients own body heat with insu- EASES OF.)
lating blankets. If the core temperature is below
28 C, then active rewarming should be insti- Hysteria
tuted by means of warm peritoneal, gastric or An out-of-date description for a symptom (or
bladder lavage or using an extracorporeal symptoms) with no obvious organic cause,
circulation. Care must be taken in moving which is an unconscious reaction and from
hypothermic patients, as a sudden rush of cold which the person may benefit. It is now recog-
peripheral blood to the heart can precipitate nised as a dissociative disorder: such disorders
ventricular fibrillation. Prevention of hypo- AMNESIA, FUGUE, multiple personality states
H
thermia in the elderly is important. Special and trancelike conditions are powerful
attention must be paid to diet, heating the defence mechanisms against severe stress when
home and adequate clothing in several layers to a patient is unable to cope with a particular
limit heat loss. problem or problems. Symptoms can also
mimic physical conditions: for example, appar-
Hypothyroidism ent paralysis or inability to speak (mutism).
Underactivity of the thyroid gland (see THYROID Mass hysteria is a phenomenon characterised by
GLAND, DISEASES OF). extreme suggestibility in a group of often emo-
tionally charged people.
Hypotonic The name originates from the ancient idea
(1) Referring to a solution which has a lower that hysteria a Greek-based word for UTERUS
osmotic pressure (see OSMOSIS) than another. was in some way associated with the womb.
Physiologically it describes a solution with a Hence the old-fashioned association of hysteria
lower osmotic pressure than body fluids. with women, and with supposed sexual dis-
(2) Muscles with abnormally reduced tone. turbances. Doctors should make sure there is
not a physical disease present to explain the
Hypoventilation symptoms before diagnosing a dissociative dis-
Shallow and/or slow breathing, often caused by order. Most subside spontaneously, but if not,
the effects of injury or drugs on the respiratory the individual needs psychiatric advice. Treat-
centre. It causes HYPERCAPNIA and HYPOXIA. ment is difficult. Reasons for stress should be
explored and, if possible, resolved. Hypnosis (see
Hypovolaemia HYPNOTISM) to help the person to relive stress-
A reduced circulating blood volume. Acutely, it ful episodes known as ABREACTION may be
is caused by unreplaced losses from bleeding, of value.
sweating, diarrhoea, vomiting or diuresis.
Chronically it may be caused by inadequate Hysteroscopy
fluid intake. Hysteroscopy is the direct visualisation of the
interior of the UTERUS using FIBREOPTIC
Hypoxaemia ENDOSCOPY. The technique, which allows
A fall in the concentration of OXYGEN in the minor surgical procedures to be carried out at
arterial blood. Symptoms are those of CYANOSIS the same time, has transformed the manage-
and, if severe, the affected individual will show ment of uterine disorders.
signs of respiratory failure.
Hysterotomy
Hypoxia An operation in which the UTERUS is opened to
A shortage of OXYGEN in the body tissues. It remove a FETUS before 28 weeks gestation.
may be caused by low inspired concentration of After 28 weeks it would be called a CAESAREAN
oxygen, an abnormal breathing pattern, lung SECTION. It is now seldom used as a means of
disease or heart disease. If severe and prolonged abortion.
 appearance at birth is of the so-called col-

I lodion baby; in the dominant form the baby is

born with universally red, moist and eroded
skin with an unpleasant smell. Gradually, over
several months, thick scales replace the
ERYTHEMA.

Iatric Treatment Minor forms are helped by con-

Anything pertaining to a physician (see also stant use of EMOLLIENTS and moisturising
DOCTOR). applications. Cream containing UREA can be
valuable. The rare erythrodermic patterns in the
Iatrogenic Disease neonate require skilled intensive care as ther-
Disease induced by a physician: most com- moregulation is disturbed and massive fluid loss
monly a drug-induced disease. occurs through the skin. Later in childhood,
oral RETINOIDS are useful.
IBD
See INFLAMMATORY BOWEL DISEASE (IBD). Icterus
Icterus is another name for JAUNDICE.
IBS
See IRRITABLE BOWEL SYNDROME (IBS). Ictus
Ictus is another term for a STROKE.
Ibuprofen
One of the NON-STEROIDAL ANTI- Identical Twins
INFLAMMATORY DRUGS (NSAIDS) with analgesic See MULTIPLE BIRTHS.
properties, Ibuprofen is used to treat rheuma-
toid arthritis and other forms of rheumatism as Idiopathic
well as headaches and muscular pains. It can Idiopathic is a term applied to diseases to indi-
cause gastric irritation and bleeding in suscep- cate that their cause is unknown.
tible individuals if used regularly.
Idiopathic Facial Nerve Palsy
ICD See BELLS PALSY.
See INTERNATIONAL CLASSIFICATION OF DISEASE
(ICD). Idiopathic Thrombocytopenic
Purpura (ITP)
Ichthammol Sometimes described as thrombocytopenia, this
Ichthammol is ammonium ichthosulphonate is an autoimmune disorder in which blood
an almost black, thick liquid of fishy smell, pre- PLATELETS are destroyed. This disturbs the
pared from a bituminous shale. It is used in bloods coagulative properties (see COAGULA-
chronic eczema (see DERMATITIS). TION) and spontaneous bleeding (PURPURA)
occurs into the skin. The disease may be acute
Ichthyosis in children but most recover without treatment.
A disorder in which the skin is permanently dry Adults may develop a more serious, chronic var-
and scaly. It is usually genetically determined iety which requires treatment with CORTICO-
and several different forms are recognised: STEROIDS and sometimes SPLENECTOMY.
Should the disease persist despite these treat-
Ichthyosis vulgaris Common and in- ments, intravenous immunoglobulin or
herited as a dominant trait. Beginning in early immunosuppressive drugs (see IMMUNOSUP-
childhood, it is often associated with atopic PRESSION) are worth trying. Should the bleed-
eczema (see DERMATITIS). The limb flexures and ing be or become life-threatening, concentrates
face are spared. of platelets should be administered.

X-linked ichthyosis is much less common, Idiosyncrasy

more severe and appears earlier than ichthyosis A generally unexpected, so unpredictable,
vulgaris. The fish-like scales are larger and abnormal reaction to a drug caused by a consti-
darker and do not spare the flexures and face. tutional defect in the patient. In some cases the
underlying disorder is already known or dis-
Ichthyosiform erythroderma Of two covered after the first event, so that the drug in
types and very rare: in the recessive form, the question can be avoided thereafter. The
 Immune System 353

abnormal sensitivity of patients with PORPHY- the rectum has usually to be removed. An ileos-
RIAS to BARBITURATES is an example. Heredi- tomy is then performed which acts as an arti-
tary biochemical defects of red blood cells are ficial anus, to which a bag is attached to collect
responsible for many drug-induced haemolytic the waste matter. Distressing though this may at
anaemias (see under ANAEMIA) and for FAVISM. first be, the vast majority of people with an ile-
Porphyria variegata, the South African variety ostomy learn to lead a fully active and normal
of porphyria, is an example of an inborn error life. Help and advice in adjusting to what can
of metabolism which was without serious be described as an ileostomy life can be
symptoms until the advent of barbiturate drugs, obtained from the Ileostomy and Internal
prescription of which is now strongly discour- Pouch Support Group.
aged. If anyone with this metabolic disorder
takes barbiturates, the consequences may be Ileum
fatal. The lower part of the small INTESTINE.

Idoxuridine Ileus
An iodine-containing antiviral agent once used Paralysis of the bowel muscle (see INTESTINE,
to treat HERPES SIMPLEX involvement of the DISEASES OF).
cornea of the EYE, its effectiveness is now
doubtful. Ilium
The uppermost of the three bones forming each I
Ifosfamide side of the PELVIS. (See also BONE.)
See CYTOTOXIC.
Illusions
Iridology See HALLUCINATIONS.
The study of the iris (see EYE). It is an old prac-
tice dating back to the days of Aristotle, and has Imidazoles
been revived as a non-conventional treatment A group of antifungal drugs active against a
(see COMPLEMENTARY AND ALTERNATIVE MEDI- wide range of fungi and yeasts (see FUNGAL AND
CINE (CAM)). YEAST INFECTIONS). Some are also effective
against bacteria and HELMINTHS. Econazole,
Ileitis clotrimazole, ketoconazole, fluconazole and
Inflammation of the ileum the lower part of itraconazole are examples: the drugs are given
the small INTESTINE. It may be caused by by mouth or externally as creams.
CROHNS DISEASE, typhoid fever (see ENTERIC
FEVER), TUBERCULOSIS or the bacterium Yers- Imipramine
inia enterocolitica. Ileitis may also accompany A well-established, relatively safe tricyclic anti-
ULCERATIVE COLITIS (see also INFLAMMATORY depressant (see ANTIDEPRESSANT DRUGS) used
BOWEL DISEASE (IBD)). to treat DEPRESSION; the drug does, however,
Patients and their relatives can obtain help have antimuscarinic and cardiac side-effects. It
and guidance from the National Association for is also used to treat ENURESIS by an action dis-
Colitis and Crohns Disease. tinct from its antidepressant effect.

Ileo-Caecal Immersion Foot

The term applied to the region of the junction The term applied to a condition which develops
between the small and large intestines in the as a result of prolonged immersion of the feet
right lower corner of the abdomen. The ileo- in cold or cool water. It was a condition
caecal valve is a structure which allows the con- commonly seen during World War II in
tents of the INTESTINE to pass onwards from the shipwrecked sailors and airmen who had
small to the large intestine, but, in the great crashed into the sea, spending long periods
majority of cases, prevents their passage in the there before being rescued. Such prolonged
opposite direction. exposure results in VASOCONSTRICTION of the
smaller arteries in the feet, leading to coldness
Ileostomy and blueness and finally, in severe cases, to
The operation by which an artificial opening is ulceration and GANGRENE. (See also TRENCH
made into the ILEUM and brought through the FOOT.)
abdominal wall to create an artificial opening or
STOMA. It is most often performed as part of the Immune System
operation for cancer of the RECTUM, in which See IMMUNITY.
 354 Immunisation

Age Disease and mode of administration

3 days BCG (Bacille Calmette-Guerin) by injection if tuberculosis in family in
past 6 months.
2 months Poliomyelitis (oral); adsorbed diphtheria, whooping-cough (pertussis)1
and tetanus2 (triple vaccine given by injection); HiB injection.3
3 months Poliomyelitis (oral); diphtheria, whooping-cough (pertussis)1 and
tetanus2 (triple vaccine given by injection); HiB injection.3
4 months Poliomyelitis (oral); diphtheria, whooping-cough (pertussis)1 and
tetanus2 (triple vaccine given by injection); HiB injection.3
1218 months Measles, mumps, and rubella (German measles)4 (given together live by
injection).
(SCHOOL ENTRY)
45 years Poliomyelitis (oral); adsorbed diphtheria and tetanus (given together by
injection); give MMR vaccine if not already given at 1218 months.
1014 females Rubella (by injection) if they have missed MMR.
1014 BCG (Bacille Calmette-Guerin) by injection to tuberculin-negative
children to prevent tuberculosis.
1518 Poliomyelitis single booster dose (oral); tetanus (by injection).
I 1
Pertussis may be excluded in certain susceptible individuals.
2
Known as DPT or triple vaccine.
3
Haemophilus influenzae immunisation (type B) is being introduced to be given at same time, but
different limb.
4
Known as MMR vaccine. (Some parents are asking to have their infants immunised with single-
constituent vaccines because of controversy over possible side-effects yet to be confirmed
scientifically of the combined MMR vaccine.)
Recommended immunisation schedules in the United Kingdom

Immunisation below). Priming the immune system in this

The introduction of antigens (see ANTIGEN) manner forms the physiological basis for
into a body to produce IMMUNITY. The table immunisation programmes.
above gives the immunisation programme Foreign substances which can provoke an
recommended by the UK departments of immune response are termed antigens. They
health. are usually proteins but smaller molecules such
as drugs and chemicals can also induce an
Immunity immune response. Proteins are taken up and
The bodys defence against foreign substances processed by specialised cells called antigen-
such as bacteria, viruses and parasites. Immun- presenting cells, strategically sited where
ity also protects against drugs, toxins and cancer microbial infection may enter the body. The
cells. It is partly non-specific that is, it does complex protein molecules are broken down
not depend on previous exposure to the foreign into short amino-acid chains (peptides see
substance. For example, micro-organisms are PEPTIDE) and transported to the cell surface
engulfed and inactivated by polymorphonu- where they are presented by structures called
clear LEUCOCYTES as a first line of defence HLA antigens (see HLA SYSTEM).
before specific immunity has developed. Foreign peptides presented by human leuco-
Acquired immunity depends upon the cyte antigen (HLA) molecules are recognised by
immune system recognising a substance as for- cells called T-lymphocytes. These originate in
eign the first time it is encountered, storing this the bone marrow and migrate to the THYMUS
information so that it can mount a reaction the GLAND where they are educated to distinguish
next time the substance enters the body. This is between foreign peptides, which elicit a pri-
the usual outcome of natural infection or mary immune response, and self-antigens (that
prophylactic IMMUNISATION. What happens is is, constituents of the person themselves) which
that memory of the initiating ANTIGEN persists do not. Non-responsiveness to self-antigens is
in selected lymphocytes (see LYMPHOCYTE). Fur- termed tolerance (see AUTOIMMUNITY). Each
ther challenge with the same antigen stimulates population or clone of T-cells is uniquely
an accelerated, more vigorous secondary responsive to a single peptide sequence because
response by both T- and B-lymphocytes (see it expresses a surface molecule (receptor)
 Immunoglobulins 355

which fits only that peptide. The responsive Immunoassay

T-cell clone induces a specific response in other Procedures which measure the concentration of
T- and B-lymphocyte populations. For any antigenic material (see ANTIGEN) to which
example, CYTOTOXIC T-cells penetrate infected an antibody (see ANTIBODIES) can be created.
tissues and kill cells which express peptides The amount of antigen bound to this antibody
derived from invading micro-organisms, is proportional to the parent substance.
thereby helping to eliminate the infection. Enzymes (see ENZYME-LINKED IMMUNOSORB-
B-lymphocytes secrete ANTIBODIES which ENT ASSAY (ELISA)) or radioactive labels (RADIO-
are collectively termed IMMUNOGLOBULINS (Ig) IMMUNOASSAY) are used to measure the concen-
see also GAMMA-GLOBULIN. Each B-cell popu- tration of antigenic material.
lation (clone) secretes antibody uniquely spe-
cific for antigens encountered in the blood, Immunodeficiency
extracellular space, and the LUMEN of organs Impaired IMMUNITY resulting from inherited or
such as the respiratory passages and gastro- acquired abnormalities of the immune system.
intestinal tract. This leads to increased vulnerability to infec-
Antibodies belong to different Ig classes; IgM tion. Important inherited examples of
antibodies are synthesised initially, followed by immunodeficiency are defects in function of
smaller and therefore more penetrative IgG GRANULOCYTES and the COMPLEMENT SYSTEM.
molecules. IgA antibodies are adapted to cross Common acquired forms of immunodeficiency
the surfaces of mucosal tissues so that they can are defective function of B-type lymphocytes
I
adhere to organisms in the gut, upper and lower and hence antibody deficiency in common
respiratory passages, thereby preventing their variable hypogammaglobulinaemia, and
attachment to the mucosal surface. IgE anti- grossly deficient CD4 T-cell function mal-
bodies also contribute to mucosal defence but functioning T-type lymphocytes in AIDS,
are implicated in many allergic reactions (see secondary to HIV infection (see AIDS/HIV).
ALLERGY).
Antibodies are composed of constant por- Immunogenicity
tions, which distinguish antibodies of different The characteristic of a substance that can pro-
class; and variable portions, which confer voke an immune response (see IMMUNITY). This
unique antigen-binding properties on the includes how foreign a substance entering or
product of each B-cell clone. In order to match contacting the body is; route of entry; dose;
the vast range of antigens that the immune sys- number and period of exposure to antigen;
tem has to combat, the variable portions are and the genetic make-up of the host. The char-
synthesised under the instructions of a large acteristics of molecules that determine
number of encoding GENES whose products immunogenicity are:
are assembled to make the final antibody. The
antibody produced by a single B-cell clone is
Foreignness: molecules recognised as self are
generally not immunogenic; the body
called a monoclonal antibody; these are now tolerates these self-molecules. To be
synthesised and used for diagnostic tests and in immunogenic, molecules must be recognised
treating certain diseases. as non-self or foreign.
Populations of lymphocytes with different
functions, and other cells engaged in immune
Molecular size: proteins with high molecular
weights (over 100,000) are the most effective
responses, carry distinctive protein markers. By immunogens; those below 10,000 are weakly
convention these are classified and enumerated immunogenic; and small ones, for example,
by their CD markers, using monoclonal anti- AMINO ACIDS, are non-immunogenic.
bodies specific for each marker.
Immune responses are influenced by
Chemical complexity: the greater the chem-
ical complexity, the more immunogenic the
cytokines which function as HORMONES acting substance.
over a short range to accelerate the activation
and proliferation of other cell populations con-
Dosage, route and timing of antigen admini-
stration: all these are important factors.
tributing to the immune response. Specific
immune responses collaborate with non- Immunoglobulins
specific defence mechanisms. These include the Immunoglobulins are a group of naturally
COMPLEMENT SYSTEM, a protein-cascade reac- occurring proteins that act as ANTIBODIES.
tion designed to eliminate antigens neutralised They are structurally related, their differences
by antibodies and to recruit cell populations determining their biological behaviour.
which kill micro-organisms. Humans have five types of immunoglobulin
with different protective functions: IgA, IgD,
 356 Immunologist

IgE, IgG and IgM. In the laboratory these are engrafted patients but also in treating eczema
separated and identified by a chemical process (see DERMATITIS).
called electrophoresis. Most antibodies have a There has been a rapid introduction in recent
molecular weight of 160,000. years of monoclonal antibodies which prevent
Certain immunoglobulins can be used in the T-cells from proliferating. They can be recog-
active or passive immunity of people against nised by the suffix mab (standing for mono-
infectious diseases such as RABIES and viral clonal antibody) and include rituximab and
HEPATITIS (see also IMMUNITY and GAMMA- alemtuzumab. Infliximab, used in CROHNS
GLOBULIN). They are also used in treating DISEASE and RHEUMATOID ARTHRITIS, inhibits
certain immunological conditions such as tumour necrosis factor alpha.
KAWASAKI DISEASE.
Immunotherapy
Immunologist The manipulation of IMMUNITY by immuno-
A specialist (medically or scientifically quali- logical (see IMMUNOLOGY) means to reduce
fied) who practises or researches IMMUNOLOGY. harmful reactions or to boost beneficial
responses. Severe ALLERGY to wasp or bee stings is
Immunology often treated by a course of injections with aller-
The study of immune responses to the gen purified from insect venom. There are cur-
environment. Its main clinical applications rent attempts to treat autoimmune diseases (see
I include improving resistance to microbial infec- AUTOIMMUNITY) with monoclonal antibodies
tions (see IMMUNITY), combating the effects of to the T-cell populations or cytokines implicated
impaired immunity (see IMMUNODEFICIENCY), in the immunopathogenesis of the disorder.
controlling harmful immune reactions (see Strategies are also being evaluated for treating
ALLERGY), and manipulating immune responses cancer by boosting the patients own immunity
(see IMMUNOTHERAPY) to prevent harmful to cancer cells. One approach is immunisation
immunological responses such as graft rejection with cancer cells manipulated in vivo to increase
and autoimmune diseases (see AUTOIMMUNITY). a T-lymphocyte attack on antigens expressed by
The clinical study of disordered immunity now tumour cells. Another method is to manipulate
forms the allied discipline of clinical immun- the cytokine network into encouraging an
ology, which is closely linked to the laboratory- immune attack on, or self-destruction (apop-
based discipline of immunopathology. tosis) of, malignant cells.
Immunotherapy is however a developing sci-
Immunosuppressant ence, and its place in the routine treatment of
A drug that reduces the bodys resistance to immunological and malignant diseases is still
infection and other foreign agents. It does so by evolving.
suppressing the activity of the immune system
(see IMMUNITY). Examples of such drugs are Impaction
AZATHIOPRINE, CYCLOPHOSPHAMIDE and A term applied to a condition in which two
CICLOSPORIN A. Immunosuppressants are used things are firmly lodged together. For example,
to help transplanted organs and tissues to sur- when one piece of bone is driven within
vive the potential immune reaction from the another following a fracture, this is known as an
host. They are also used to treat AUTOIMMUNE impacted fracture; when a tooth is firmly
DISORDERS such as RHEUMATOID ARTHRITIS. lodged in its socket so that its eruption is pre-
vented, this is known as dental impaction.
Immunosuppression Intractable constipation is termed faecal
The term given to suppression of harmful impaction.
immune responses (see IMMUNITY), the most
obvious application being the prevention of Imperforate
organ rejection by people who receive kidney, An adjective meaning lack of an opening. For
heart or bone-marrow transplants (see TRANS- example, occasionally the ANUS fails to develop
PLANTATION). Immunosuppression is also used properly, resulting in partial or complete obstruc-
in certain diseases in a way that is non-specific tion of the opening. Sometimes pubertal girls
that is, it inhibits the entire immune system, have an imperforate HYMEN which obstructs the
not just harmful reactions. CORTICOSTEROIDS opening to the VAGINA and prevents menstrual
are the commonest dugs used in this way, as are flow of blood draining to the exterior.
METHOTREXATE and AZATHIOPRINE. Tac-
rolimus, a macrolide (see MACROLIDES) Impetigo
IMMUNOSUPPRESSANT, is used not only for An infectious skin disease caused usually by
 Inbreeding 357

Staphylococcus aureus and less often by Strepto- severe disturbance of health, such as DIABETES
coccus pyogenes. The itching rash is seen espe- MELLITUS; and addiction to alcohol.
cially on the face but may spread widely. An oral drug for treating erectile function is
Vesicles and pustules erupt and dry to form sildenafil citrate (Viagra), the first in a new
yellow-brown scabs. Untreated, the condition class of drugs called phosphodiesterase type 5
may last for weeks. In very young infants, large inhibitors, also including tadalafil (Cialis)
blisters may form (bullous impetigo). and vardenafil (Levitra). They work by
improving blood flow to the penis. They can be
Treatment Crusts should be gently removed taken an hour before intercourse (up to 12
with SALINE. Mild cases respond to frequent hours before, in the case of tadalafil). These
application of mupiricin or NEOMYCIN/BACI- drugs are not aphrodisiacs, and side-effects
TRACIN ointment; more severe cases should be include headache, facial flushing and indiges-
treated orally or, sometimes, intravenously with tion. There are some suggestions that they may
FLUCLOXACILLIN or one of the CEPHALO- affect retinal function.
SPORINS. If the patient is allergic to penicillin, Intracavernosal injection or urethral applica-
ERYTHROMYCIN can be used. tion of alprostadil, a drug which increases local
For severe, intractable cases, an oral retinoid blood supply to the penis, has been used for
drug called isotretinoin (commercially pro- some years under medical supervision, but suc-
duced as Roaccutane) can be used. It is given cess has been variable and oral sildenafil seems
systemically but treatment must be supervised to be a more convenient and effective treatment I
by a consultant dermatologist as serious side- for a man with this disorder.
effects, including possible psychiatric disturb-
ance, can occur. The drug is also teratogenic (see Impression
TERATOGENESIS), so women who are, or who In dentistry, a mould (using a rubber or alginate
may become, pregnant must not take isotretin- compound) of the teeth and gums from which a
oin. It acts mainly by suppressing SEBUM pro- plaster-of-Paris model is prepared. This model
duction in the sebaceous glands and can be very provides a base on which to construct a den-
effective. Recurrent bouts of impetigo should ture, bridge or dental inlay. A similar process is
raise suspicion of underlying SCABIES or head used in ORTHODONTICS to make dental appli-
lice. Bactericidal soaps and instilling an anti- ances to correct abnormalities in the position-
biotic into the nostrils may also help. ing of teeth.

Implantation Imprinting
(1) The placing of a substance such as a drug, or In the context of animal behaviour, this is a
an object such as a pacemaker, in a body tissue. quick and irreversible type of learning in which
(2) The surgical replacement of injured or patterns are imprinted on the animals mind
unhealthy tissue or organ with healthy tissue or during the first few hours of life. The smell and
organ (also known as TRANSPLANTATION). feel of its mother are one such imprint.
(3) Attachment of the early EMBRYO to the lin-
ing of the UTERUS, which occurs around six IMR
days after conception; the site where this hap- See INFANT MORTALITY RATE (IMR).
pens is where the placenta will develop.
Inanition
Impotence Exhaustion in an individual caused by lack of
Inability of the male to perform the sexual act. appropriate nutrients in the circulating blood.
It may be partial or complete, temporary or Starvation, malnutrition or intestinal disorders
permanent. Psychological factors are the most are among the causes.
common cause and these include anxiety,
ignorance, fear, guilt, weakness of sexual desire Inbreeding
or abnormality of such desire. Counselling or The birth of offspring to parents who are
sex therapy, preferably with the partner, has a closely related (see CONSANGUINOUS). In trad-
50-per-cent chance of helping to cure long- itional rural communities, marriage between
term impotence of psychological origin. Among cousins was common and this could lead to a
organic causes are lesions (see LESION) of the higher-than-average number of children with
external genitalia; disturbances of the ENDO- congenital anomalies or learning difficulties.
CRINE GLANDS, such as diminished activity of This is now seen in certain ethnic groups who
the gonads, thyroid gland or pituitary gland; have brought the custom of inbreeding with
diseases of the central NERVOUS SYSTEM; any them to their new homes in the western world.
 358 Incidence

Incidence ence due to an overactive URINARY BLADDER

One of the main ways to measure the frequency also called detrusor instability which affects
of a disease in a particular population. The one-third of incontinent women, prevalence
incidence of a disease is the number of new increasing with age. Bladder symptoms do not
cases that occur during a particular time. necessarily correlate with the underlying diag-
PREVALENCE, the other measure, is the total nosis, and accurate diagnosis may require uro-
number of cases of disease present at any one dynamic studies examination of urine within,
time and covers both old and new cases. and the passage of urine through and from, the
urinary tract. However, such studies are best
Incision deferred until conservative treatment has failed
A cut or wound; a term especially applied to or when surgery is planned.
surgical openings. Incontinence causes embarassment, incon-
venience and distress in women, and men are
Incisor reluctant to seek advice for what remains a
The term for the four front TEETH of each jaw. social taboo for most people. Sufferers should
be encouraged to seek help early and to discuss
Inclusion Bodies their anxieties and problems frankly. Often it is
Particles found in the CYTOPLASM and a condition which can be managed effectively at
NUCLEUS of CELLS, usually a consequence of a primary care centres, and quite simple measures
I viral infection. This phenomenon can be help- can greatly improve the lives of those affected.
ful in the diagnosis of such an infection. STRESS INCONTINENCE is the most common
cause of urinary incontinence in women. This
Incompatibility is the involuntary loss of urine during activities
(1) In the pharmacological context, the use of that raise the intra-abdominal pressure, such as
two or more drugs in treatment which together sneezing, coughing, laughing, exercise or lift-
produce adverse consequences for the patient. ing. The condition is caused by injury or weak-
The British National Formulary carries an ness of the urethral sphincter muscle; this
appendix devoted to drug interactions. weakness may be either congenital or the result
(2) In the haematological context, an adverse of childbirth, PROLAPSE of the VAGINA, MENO-
reaction in a patient given a blood TRANSFU- PAUSE or previous surgery. A CYSTOCOELE may
SION in which the donor blood is incompatible be present. Urinary infection may cause
with that of the recipient. incontinence or aggravate the symptoms of
existing incontinence.
Incompetence The first step is to diagnose and treat infec-
Incompetence is a term applied to the valves of tion, if present. Patients benefit from simple
the heart when, as a result of disease in the advice on incontinence pads and garments, and
valves or alterations in size of the chambers of on fluid intake. Those with a high fluid intake
the heart, the valves become unable to close the should restrict this to a litre a day, especially if
orifices which they should protect. (See HEART, frequency is a problem. Constipation should be
DISEASES OF.) treated and smoking stopped. The use of
DIURETICS should be reduced if possible, or
Incontinence stopped entirely. Postmenopausal women may
benefit from oestrogen-replacement therapy;
Urinary incontinence The International elderly people with chronic incontinence may
Continence Society defines urinary incontin- need an indwelling urethral catheter.
ence as an involuntary loss of URINE that is Pelvic-floor exercises can be successful and
objectively shown and is a social and hygiene the insertion of vaginal cones can be a useful
problem. The elderly suffer most from this dis- subsidiary treatment, as can electrical stimula-
order because the effectiveness of the sphincter tion of the pelvic muscles. If these procedures
muscles surrounding the URETHRA declines are unsuccessful, then continence surgery may
with age. Men are less often affected than be necessary. The aim of this is to raise the neck
women; 20 per cent of women over 40 years of of the bladder, support the mid part of the
age have problems with continence. It is esti- urethra and increase urethral resistance. Several
mated that around three million people are techniques are available.
regularly incontinent in the UK, a prevalence of URGE INCONTINENCE An overactive or
about 40 per 1,000 adults. unstable bladder results in urge incontinence,
Incontinence can be divided broadly into also known as detrusor incontinence the
two groups: stress incontinence and incontin- result of uninhibited contractions of the detru-
 Indinavir 359

sor muscle of the bladder. The bladder con- in question. A person who has been exposed to
tracts (spontaneously or on provocation) during infection is, during the incubation period,
the filling phase while the patient attempts to technically known as a contact. By isolating and
stop passing any urine. Hyperexcitability of the watching contact cases, medical officers can
muscle or a disorder of its nerve supply are often successfully check a threatened EPIDEMIC.
likely causes. The symptoms include urgency It must be noted that diseases are not com-
(acute wish to pass urine), frequency and stress municated to others by a person who is incubat-
incontinence. Diagnosis can be confirmed with ing an illness. Some diseases, however, such as
CYSTOMETRY. Bladder training is the first step MEASLES, become infectious as soon as the first
in treatment, with the aim of reducing the fre- symptoms set in after the incubation period is
quency of urination to once every three to four over; others, like SCARLET FEVER and SMALL-
hours. BIOFEEDBACK, using visual, auditory or POX, are not so infectious then as in their later
tactile signals to stop bladder contractions, will stages. The incubation period for any given dis-
assist the bladder training. Drug treatments ease is remarkably constant, although in the
such as CALCIUM-CHANNEL BLOCKERS, case of a severe attack the incubation is usually
antimuscarinic agents (see ANTIMUSCARINE), slightly shortened, and if the oncoming attack
TRICYCLIC ANTIDEPRESSANT DRUGS, and oes- is a mild one, the period may be lengthened.
trogen replacement can be effective. Surgery is All, however, may take a few days longer than
rarely used and is best reserved for difficult the time stated to show themselves (see INFEC-
cases. TION), and several especially WHOOPING-
I
OVERFLOW INCONTINENCE Chronic urinary COUGH may be difficult to recognise in their
retention with consequent overflow more early stages.
common in men than in women. The causes Incubation periods of the more common
include antispasmodic drugs, continence sur- infectious diseases:
gery, obstruction from enlargement and post-
prostatectomy problems (in men), PSYCHOSIS, days
and disease or damage to nerve roots arising Chickenpox 1421
from the spinal cord. Urethral dilatation or Diphtheria 25
urethrotomy may be required when obstruction German measles 1421
is the cause. Management is intermittent self- Measles 1015
catheterisation or a suprapubic catheter and Mumps 1821
treatment of any underlying cause. Poliomyelitis 321
Smallpox 1016
Faecal incontinence is the inability to Typhoid fever 721
control bowel movements and may be due to Whooping-cough 710
severe CONSTIPATION, especially in the elderly;
to local disease; or to injury or disease of the Index Finger
spinal cord or nervous supply to rectum and The forefinger or second digit of the hand.
anal muscles. Those with the symptom require
further investigation. Index Medicus
A monthly publication produced by the
Incoordination National Library of Medicine in the USA. The
A term applied to irregularity of movements publication indexes leading biomedical litera-
produced either by loss of the sensations by ture from throughout the world. Indexing is by
which they are governed, or by defects in the author and by subject.
muscles themselves or somewhere in the ner-
vous system. Indian Hemp
See CANNABIS.
Incubation
The period elapsing between the time when a Indigestion
person becomes infected by some agent and the See DYSPEPSIA.
first appearance of the symptoms of the disease.
Most acute infectious diseases have fairly def- Indinavir
inite periods of incubation, and it is of great A protease-inhibitor antiviral drug used in com-
importance that people who have run the risk bination with nucleoside reverse transcriptase
of infection should know the length of time inhibitors (see REVERSE TRANSCRIPTASE
which must elapse before they can be sure INHIBITOR) to treat HIV infection (see AIDS/
whether or not they are to contract the disease HIV). A drug with a range of potentially serious
 360 Indispensable Amino Acids

side-effects, its use should be coupled with onset and type of disability are among the most
counselling and monitoring of the effects. important. Industrial includes almost all forms
of employment. In addition to accidents, there
Indispensable Amino Acids is a long list of prescribed industrial diseases
This is the new, preferred term for essential ranging from BURSITIS, hearing loss, ASTHMA
amino acids amino acids which are essential and viral HEPATITIS to unusual ones such as
for the bodys normal growth and development, ORF. Psychological as well as physical disable-
but which the body is unable to produce. Nine ment may attract benefit, which is calculated on
essential amino acids exist HISTIDINE, ISO- a percentage basis according to the extent of
LEUCINE, LEUCINE, LYSINE, METHIONINE, disability. The onus is on the individual to
PHENYLALANINE, THREONINE, TRYPTOPHAN, claim, and trade unions and representative
and VALINE and they are present in foods organisations can advise on procedures. Injured
rich in protein: dairy products, eggs, meat, and employees should always report details of an
liver. accident to their employer and record it in the
accident book promptly: even seemingly minor
Indometacin injuries may subsequently lead to some dis-
Previously indomethacin, this is one of many ability. Relevant information leaflets are avail-
drugs used in the treatment of GOUT and able for example, from local benefit agencies,
RHEUMATOID ARTHRITIS. A proprionic-acid local-authority advice centres and public
I derivative, it may help to relieve night pain and libraries.
morning stiffness. It is also used to treat the
congenital abnormality of the heart known as Infant
DUCTUS ARTERIOSUS. A baby who is under one year old.
Indoramin Infant Feeding
An alpha-adrenoreceptor-blocking drug used in The newborn infant may be fed naturally from
the treatment of high blood pressure. It has sev- the breast, or artificially from a bottle.
eral side-effects including sleepiness, dizziness,
depression and failure to ejaculate. (See ALPHA Breast feeding Unless there is a genuine
ADRENERGIC BLOCKERS; ADRENERGIC
contraindication, every baby should be breast
RECEPTORS.)
fed. The nutritional components of human
Induction milk are in the ideal proportions to promote the
Bringing about a particular event for example, healthy growth of the human newborn. The
the induction or starting of labour (see PREG- mothers milk, especially colostrum (the fluid
NANCY AND LABOUR), or the induction of
secreted before full lactation is established) con-
ANAESTHESIA. Newly arrived hospital doctors
tains immune cells and antibodies that increase
are given an induction period during their first the babys resistance to infection. From the
day or two at work. mothers point of view, breast feeding helps the
womb to return to its normal size and helps her
Induration to lose excess body fat gained during pregnancy.
The pathological hardening of a tissue or organ. Most importantly, breast feeding promotes
This may occur when a tissue is infected or intimate contact between mother and baby. A
when it is invaded by cancer. (See also final point to be borne in mind, however, is that
SCLEROSIS.) drugs taken by a mother can be excreted in her
milk. These include antibiotics, sedatives, tran-
Industrial Diseases quillisers, alcohol, nicotine and high-dose ster-
See OCCUPATIONAL HEALTH, MEDICINE AND oids or vitamins. Fortunately this is rarely a
DISEASES. cause of trouble. (See also main entry on
BREAST FEEDING.)
Industrial Injuries Benefit
The Industrial Injuries Scheme provides money Artificial feeding Unmodified cows milk
for people who have suffered injury or illness is not a satisfactory food for the human new-
because of their work. Benefits for born and may cause dangerous metabolic
employment-related disability (self- imbalance. If breast feeding is not feasible, one
employment is excluded) have been altered of the many commerciallly available formula
many times since they were introduced in 1948. milks should be used. Most of these are made
There is now a mix of benefits, eligibility for from cows milk which has been modified to
which depends on several factors: the date, reflect the composition of human milk as
 Infantile Spasms 361

closely as possible. For the rare infant who can arouse extreme maternal anxiety by refusing
develops cows-milk-protein intolerance, a milk to eat. This can lead to force-feeding and battles
based on soya-bean protein is indicated. of will which may culminate in a breakdown of
the mother-child relationship. To avoid this,
Feeding and weight gain The main parents must resist the temptation to coax the
guide as to whether an infant is being child to eat. If the child refuses solid food, the
adequately fed is the weight. During the first meal should be taken away with a minimum of
days of life a healthy infant loses weight, but fuss. Childrens appetites reflect their individual
should by the end of the second week return to genetic structure and a well child will eat
birth weight. From then on, weight gain should enough to grow and maintain satisfactory
be approximately 6oz. (170g) each week. weight gain. If a child is not eating properly,
The timing of feeds reflects social convention weight gain will be inadequate over a prolonged
rather than natural feeding patterns. Among period and an underlying illness is the most
the most primitive hunter-gatherer tribes of likely cause. Indeed, failure to thrive is the
South America, babies are carried next to the paediatricians best clue to chronic illness.
breast and allowed to suckle at will. Fortunately
for developed society, however, babies can be Advice on feeding Many sources of con-
conditioned to intermittent feedings. flicting advice are available to new parents. It is
As the timing of breast feeding is flexible impossible to satisfy everyone, and ultimately it
little or no preparation time being required is the well-being of the mother and infant and I
mothers can choose to feed their babies on the closeness of their relationship that matter.
demand. Far from spoiling the baby, demand In general, mothers should be wary of rigid
feeding is likely to lead to a contented infant, advice. An experienced midwife, health visitor
the only necessary caution being that a crying or well-baby-clinic nursing sister are among the
baby is not always a hungry baby. most reliable sources of information.
In general, a newborn will require feeding
every two to four hours and, if well, is unlikely Protein Fat per Sugar Calories
to sleep for more than six hours. After the first per cent cent per cent per cent
months, a few lucky parents will find their Human milk 11 42 70 70
Cows milk 35 39 46 66
infant sleeping through the night.
Composition of human and cows milk
Weaning Weaning on to solid foods is again
a matter of individuality. Most babies will Infantile Paralysis
become dissatisfied with a milk-only diet at An old name for POLIOMYELITIS.
around six months and develop enthusiasm for
cereal-based weaning foods. Also at about this Infantile Spasms
time they enjoy holding objects and transfer- Also known as salaam attacks, these are a rare
ring them to their mouths the mouth being but serious type of EPILEPSY, usually starting in
an important sense organ in infants. It is logical the first eight months of life. The spasms are
to include food items that they can hold, as this short and occur as involuntary flexing of the
clearly brings the baby pleasure at this time. neck, arms, trunk and legs. They may occur
Introduction of solids before the age of four several times a day. If the baby is sitting, it may
months is unusual and best avoided. The usual collapse into a salaam position; more usually
reason given for early weaning is that the baby there is a simple body jerk, sometimes accom-
appears hungry, but this is unlikely to be the panied by a sudden cry. An electroencephalo-
case; crying due to COLIC, for example, is more gram (see ELECTROENCEPHALOGRAPHY (EEG))
probable. Some mothers take the babys desire shows a picture of totally disorganised electrical
to suck say, on their finger as a sign of activity called hypsarrhythmia. The condition
hunger when this is, in fact, reflex activity. results from any one of many brain injuries,
Delaying the start of weaning beyond nine infections or metabolic insults that may have
months is nutritionally undesirable. As weaning occurred before, during, or in the first few
progresses, the infants diet requires less milk. months after birth. Its importance is that in
Once established on a varied solid diet, breast most cases, the babys development is seriously
and formula milks can be safely replaced with affected such that they are likely to be left with
cows milk. There is, however, no nutritional a profound learning disability. Consequently,
contraindication to continued breast feeding prompt diagnosis is important. Treatment is
until the mother wishes to stop. with CORTICOSTEROIDS or with certain anti-
It is during weaning that infants realise they convulsants the hope being that prompt and
 362 Infantilism

aggressive treatment might prevent further It is thus evident that for a reduction of the
brain damage leading to learning disability. infant mortality rate to the minimum figure,
the following conditions must be met. Mothers
Infantilism and potential mothers must be housed
The condition characterised by imperfect sexual adequately in healthy surroundings, particularly
development at puberty. It may or may not be with regard to safe water supplies and sewage
associated with small stature, and may be due to disposal. The pregnant and nursing mother
lack of development of certain of the ENDO- must be ensured an adequate diet. Effective
CRINE GLANDS: for example, the gonads, pituit- antenatal supervision must be available to every
ary gland or adrenal glands. In other cases it mother, as well as skilled supervision during
may be associated with a generalised disease labour (see PREGNANCY AND LABOUR). The
such as diabetes mellitus, asthma, ulcerative col- newborn infant must be adequately nursed and
itis and rheumatoid arthritis (for more informa- fed and mothers encouraged to breast feed.
tion, see under separate entries). Environmental and public-health measures
must be taken to ensure adequate housing, a
Infant Mortality Rate (IMR) clean milk supply and full availability of med-
The number of deaths of infants under one year ical care including such protective measures as
of age. The IMR in any given year is calculated IMMUNISATION against diphtheria, measles,
as the number of deaths in the first year of life poliomyelitis and whooping-cough. (See also
I in proportion to every 1,000 registered live PERINATAL MORTALITY.)
births in that year. Along with PERINATAL MOR-
TALITY, it is accepted as one of the most Infarction
important criteria for assessing the health of the The changes in an organ when an artery is sud-
community and the standard of the social con- denly blocked, leading to the formation of a
ditions of a country. dense, wedge-shaped mass of dead tissue in the
The improvement in the infant mortality part of the organ supplied by the artery. It
rate has occurred mainly in the period from the occurs as the result of EMBOLISM or of
second month of life. There has been much less THROMBOSIS.
improvement in the neonatal mortality rate
that is, the number of infants dying during the Infection
first four weeks of life, expressed as a proportion The process by which a disease is transmitted
of every 1,000 live births. During the first week via micro-organisms from one person to
of life the main causes of death are asphyxia, another. The micro-organism may be a bac-
prematurity, birth injuries and congenital terium (see BACTERIA), a RICKETTSIA, a VIRUS, a
abnormalities. After the first week the main protozoon single-celled animal organism or
cause of death is infection. a metazoon multicellular animal organism.
Social conditions also play an important role Invasion of the body by a metazoon (e.g. by an
in infant mortality. In England and Wales the intestinal worm) is more often known as an
infant mortality rate in 193032 was: Social infestation.
Class I (professional), 327; Social Class III The skin is an important protection against
(skilled workers), 576; Social Class V micro-organisms entering the body tissues. A
(unskilled workers), 771. Many factors come large measure of protection is afforded by the
into play in producing these social variations, factors which ensure IMMUNITY against
but overcrowding is undoubtedly one of the diseases.
most important.
Modes of infection The infective material
may be transmitted to the person by direct con-
18389 146 195052 30
tact with a sick person, when the disease is said
185160 154 196062 22
to be contagious, although such a distinction is
190002 142 197072 18
purely artificial. Different diseases are especially
191012 110 198082 12
infectious at different periods of their course.
192022 82 199092 7
Protecting people can be difficult, since some
193032 67 1996 62
diseases are infectious before the patient shows
194042 59 1999 5.8
any symptoms (see INCUBATION).
2000 5.6
Infection may be conveyed on dust, in
Infant mortality rate in the United Kingdom drinking-water, in food (particularly milk), in
18382000. Deaths of infants under 1 year the bodys waste products and secretions, or
age per thousand live births
even on clothes and linen which have been in
 Infertility 363

contact with the infected individual (called partners are affected. Couples should be
fomites). investigated together as efficiently and quickly
Some people who have recovered from a dis- as possible to decrease the distress which is
ease, or who have simply been in contact with invariably associated with the diagnosis of
an infectious case, harbour the infectious agent. infertility. In about 1015 per cent of women
This is particularly the case in typhoid fever (see suffering from infertility, ovulation is disturbed.
ENTERIC FEVER), the bacillus continuing to Mostly they will have either irregular periods or
develop in the gall-bladder of some people who no periods at all (see MENSTRUATION).
have had the disease for years after the symp- Checking a hormone profile in the womans
toms have disappeared. In the case of CHOLERA, blood will help in the diagnosis of ovulatory
which is ENDEMIC in some developing coun- disorders like polycystic ovaries, an early meno-
tries with hot climates, 80 per cent or more of pause, anorexia or other endocrine illnesses.
the population may harbour the bacillus and Ovulation itself is best assessed by ultrasound
spread infection when other circumstances scan at mid-cycle or by a blood hormone pro-
favour this. Similarly in the case of DYSENTERY, gesterone level in the second half of the cycle.
people who have completely recovered may still The FALLOPIAN TUBES may be damaged or
be capable of infecting dust and drinking-water blocked in 2030 per cent of infertile women.
by their stools. DIPHTHERIA and meningococcal This is usually caused by previous pelvic infec-
MENINGITIS, which is particularly liable to tion or ENDOMETRIOSIS, where menstrual
infect children, are other examples. blood is thought to flow backwards through the I
Flies can infect milk and other food with the fallopian tubes into the pelvis and seed with
organisms causing typhoid fever and food poi- cells from the lining of the uterus in the pelvis.
soning. Mosquitoes carry the infective agents of This process often leads to scarring of the pelvic
MALARIA, DENGUE and YELLOW FEVER, these tissues; 510 per cent of infertility is associated
undergoing part of their development in the with endometriosis.
body of the mosquito. Fleas convey the germ of To assess the Fallopian tubes adequately a
plague from rats to humans, and lice are procedure called LAPAROSCOPY is performed. An
responsible for inoculating TYPHUS FEVER and ENDOSCOPE is inserted through the umbilicus
one form of RELAPSING FEVER by their bite. A and at the same time a dye is pushed through
tick is responsible for spreading another form of the tubes to assess their patency. The procedure
relapsing fever, and kala-azar (LEISHMANIASIS) is is performed under a general anaesthetic.
spread by the bites of sandflies. In a few cases the mucus around the cervix
may be hostile to the partners sperm and there-
Notifiable diseases Certain of the com- fore prevent fertilisation.
mon and most serious infectious diseases are Defective production is responsible for up to
notifiable in the United Kingdom. A doctor a quarter of infertility. It may result from the
diagnosing someone infected by a notifiable failure of the testes (see TESTICLE) to descend in
disease must inform the authorities. For the early life, from infections of the testes or previ-
current list of notifiable infectious diseases in ous surgery for testicular torsion. The semen is
the UK, see the main entry for NOTIFIABLE analysed to assess the numbers of sperm and
DISEASES. their motility and to check for abnormal forms.
Prevention is an important aspect of the con- In a few cases the genetic make-up of one
trol of infectious diseases, and various steps can partner does not allow the couple ever to
be taken to check the spread of such infections achieve a pregnancy naturally.
as dysentery, tuberculosis, malaria and others. In about 25 per cent of couples no obvious
(See also IMMUNITY; INCUBATION.) cause can be found for their infertility.

Infectious Mononucleosis Treatment Ovulation may be induced with

See MONONUCLEOSIS. drugs.
In some cases damaged Fallopian tubes may
Infertility be repaired by tubal surgery. If the tubes are
This is diagnosed when a couple has not destroyed beyond repair a pregnancy may be
achieved a pregnancy after one year of regular achieved with in vitro fertilisation (IVF) see
unprotected sexual intercourse. Around 1520 under ASSISTED CONCEPTION.
per cent of couples have difficulties in conceiv- Endometriosis may be treated either with
ing; in half of these cases the male partner is drugs or laser therapy, and pregnancy rates after
infertile, while the woman is infertile also in both forms of treatment are between 4050 per
half; but in one-third of infertile couples both cent, depending on the severity of the disease.
 364 Infestation

Few options exist for treating male-factor years. The diseases are similar and are both clas-
infertility. These are artificial insemination by sified as IBD, but a significant distinction is
husband or donor and more recently in vitro that Crohns disease can affect any part of the
fertilisation. Drug treatment and surgical repair GASTROINTESTINAL TRACT from mouth to
of VARICOCELE have disappointing results. anus, whereas ulcerative colitis affects only the
Following investigations, between 30 and 40 COLON. The incidence of IBD varies widely
per cent of infertile couples will achieve a preg- between countries, being rare in the developing
nancy usually within two years. world but much more common in westernised
Some infertile men cannot repair any errors nations, where the incidence of Crohns disease
in the DNA in their sperm, and it has been is around 57 per 100,000 (and rising) and that
found that the same DNA repair problem of ulcerative colitis at a broadly stable 10 per
occurs in malignant cells of some patients with 100,000. It is common for both disorders to
cancer. It is possible that these mens infertility develop in young adults, but there is a second
might be natures way of stopping the propaga- spike of incidence in people in their 70s. Details
tion of genetic defects. With the assisted repro- about the two disorders are given under the
duction technique called intracytoplasmic individual entries elsewhere in the dictionary.
sperm injection, some men with defective sperm Inflammatory bowel disease should not be con-
can fertilise an ovum. If a man with such DNA fused with IRRITABLE BOWEL SYNDROME (IBS)
defects fathers a child via this technique, that which has some of the same symptoms of IBD
I child could be sterile and might be at increased but a different cause and outcome.
risk of developing cancer. (See ARTIFICIAL
INSEMINATION; ASSISTED CONCEPTION.) Infliximab
An IMMUNOSUPPRESSANT monoclonal anti-
Infestation body (see ANTIBODIES) designed to inhibit the
A term applied to the occurrence of animal pro-inflammatory cytokine (see CYTOKINES),
parasites in the intestine, hair or clothing. tumour necrosis factor alpha. It is used in treating
CROHNS DISEASE and RHEUMATOID ARTHRITIS.
Infibulation
The most extensive form of female CIRCUMCI- Influenza
SION, involving removal of CLITORIS and both Influenza is an acute infectious disease, charac-
LABIA. terised by a sudden onset, fever and generalised
aches and pains. It usually occurs in epidemics
Infiltration and pandemics (see EPIDEMIC; PANDEMIC).
The invasion of tissues or organs by cells or
fluid not normally present for example, local Cause The disease is caused by a VIRUS of the
anaesthetic is infiltrated into an area of tissue to influenza group. There are at least three types of
produce analgesia in a defined area. influenza virus, known respectively as A, B and
C. One of their most characteristic features is
Inflammation that infection with one type provides no protec-
The reaction of the tissues to any injury, which tion against another. Equally important is the
may be the result of trauma, infection or chem- ease with which the influenza virus can change
icals. Local blood vessels dilate, thus increasing its character. It is these two characteristics
blood flow to the injured site. White blood cells which explain why one attack of influenza pro-
invade the affected tissue, engulfing bacteria or vides little, if any, protection against a sub-
other foreign bodies; related cells consume any sequent attack, and why it is so difficult to
dead cells, thus producing PUS after which the prepare an effective vaccine against the disease.
site starts to heal. The patient feels pain and the Epidemics of influenza due to virus A occur
affected tissue becomes hot, red and swollen, in Britain at two- to four-year intervals, and
with its functioning affected. If the infection outbreaks of virus B influenza in less frequent
is severe it may persist locally chronic cycles. Virus A influenza, for instance, was the
inflammation or spread elsewhere in the body prevalent infection in 1949, 1951, 1955 and
systemic infection. 1956, whilst virus B influenza was epidemic in
1946, 1950, 1954 and, along with virus A, in
Inflammatory Bowel Disease 195859. The pandemic of 1957, which swept
(IBD) most of the world, although fortunately not in a
CROHNS DISEASE and ULCERATIVE COLITIS are severe form, was due to a new variant of virus A
chronic inflammatory diseases characterised by the so-called Asian virus and it has been
relapsing and remitting episodes over many suggested that it was this variant that was
 Information Technology in Medicine 365

responsible for the pandemics of 1889 and boarding schools, elderly people, and people
1918. Since 1957, variants of virus A have been who suffer from chronic bronchitis or asthma,
the predominating causes of influenza, accom- chronic heart disease, renal failure, diabetes
panied on occasions by virus B. mellitus or immunosuppression (see under sep-
In 1997 and 2004, outbreaks of Chinese arate entries). In the face of an epidemic, people
avian influenza caused alarm. The influenza in key positions, such as doctors, nurses and
virus had apparently jumped species from birds those concerned with public safety, transport
probably chickens to infect some people. and other public utilities, should be vaccinated.
Because no vaccine is available, there was a risk For an uncomplicated attack of influenza,
that this might start an epidemic. treatment is symptomatic: that is, rest in bed,
ANALGESICS to relieve the pain, sedatives, and a
Symptoms The incubation period of influ- light diet. A linctus is useful to sooth a trouble-
enza A and B is 23 three days, and the disease some cough. The best analgesics are ASPIRIN or
is characterised by a sudden onset. In most cases PARACETAMOL. None of the sulphonamides or
this is followed by a short, sharp febrile illness the known antibiotics has any effect on the
of 24 days duration, associated with head- influenza virus; on the other hand, should the
ache, prostration, generalised aching, and lungs become infected, antibiotics should be
respiratory symptoms. In many cases the given immediately, because such an infection is
respiratory symptoms are restricted to the upper usually due to other organisms. If possible, a
respiratory tract, and consist of signs of irrita- sample of sputum should be examined to I
tion of the nose, pharynx and larynx. There determine which organisms are responsible for
may be nosebleeds, and a dry, hacking cough is the lung infection. The choice of antibiotic
often a prominent and troublesome symptom. then depends upon which antibiotic the organ-
The fever is usually remittent and the tempera- ism is most sensitive to.
ture seldom exceeds 394 C (103 F), tending
to fluctuate between 383 and 394 C (101 Information Technology in
and 103 F). Medicine
The most serious complication is infection of The advent of computing has had widespread
the lungs. This infection is usually due to effects in all areas of society, with medicine no
organisms other than the influenza virus, and is exception. Computer systems are vital as they
a complication which can have serious results in are in any modern enterprise for the adminis-
elderly people. tration of hospitals, general practices and health
The very severe form of flu which tends to authorities, supporting payroll, finance, stock
occur during pandemics and which was so ordering and billing, resource and bed man-
common during the 191819 pandemic is agement, word-processing correspondence,
characterised by the rapid onset of broncho- laboratory-result reporting, appointment and
pneumonia and severe prostration. Because of record systems, and management audit.
the toxic effect on the heart, there is a particu- The imaging systems of COMPUTED TOM-
larly marked form of CYANOSIS, known as OGRAPHY (CT) and magnetic resonance
heliotrope cyanosis. imaging (see MRI) have powerful computer
Convalescence following influenza tends to techniques underlying them.
be prolonged. Even after an attack of average Computerised statistical analysis of study
severity there tends to be a period of weakness data, population databases and disease registries
and depression. is now routine, leading to enhanced under-
standing of the interplay between diseases and
Treatment Expert opinion is still divided as the population. And the results of research,
to the real value of influenza vaccine in prevent- available on computerised indexes such as
ing the disease. Part of the trouble is that there MEDLINE, can be obtained in searches that take
is little value in giving any vaccine until it is only seconds, compared with the hours or days
known which particular virus is causing the necessary to accomplish the same task with its
infection. As this varies from winter to winter, paper incarnation, Index Medicus.
and as the protection given by vaccine does not
exceed one year, it is obviously not worthwhile Medical informatics The direct com-
attempting to vaccinate the whole community. puterisation of those activities which are
The general rule therefore is that, unless there is uniquely medical history-taking, examin-
any evidence that a particularly virulent type of ation, diagnosis and treatment has proved an
virus is responsible, only the most vulnerable elusive goal, although one hotly pursued by
should be immunised such as children in doctors, engineers and scientists working in the
 366 Information Technology in Medicine

discipline of medical informatics. Computer least the fact that for such systems to work, the
techniques have scored some successes: patients whole organisation, and not just a few special-
are, for example, more willing to be honest ised individuals, must become computer liter-
about taboo areas, such as their drug or alcohol ate. Such systems must be easy to learn to use,
consumption, or their sexual proclivities, with a which requires an intuitive interface between
computer than face to face with a clinician; user(s) and system(s) that is predictable and
however, the practice of taking a history logical in its ordering and presentation of
remains the cornerstone of clinical practice. information.
The examination of the patient is unlikely to be Many other issues stand in the way of the
supplanted by technological means in the development towards computerisation: stand-
foreseeable future; visual and tactile recognition ard systems of nomenclature for medical con-
systems are still in their infancy. Skilled inter- cepts have proved surprisingly difficult to
pretation of the result by machine rather than develop, but are crucial for successful
the human mind seems equally as remote. information-sharing between users. Sharing
Working its way slowly outwards from its start- information between existing legacy systems is a
ing point in mathematical logic, ARTIFICIAL major challenge, often requiring customised
INTELLIGENCE that in any way mimics its software and extensive human intervention to
natural counterpart seems a distant prospect. enable the previous investments that an organ-
Although there have been successes in isation has made in individual systems (e.g.
I computer-supported diagnosis in some special- laboratory-result reporting) to be integrated
ised areas, such as the diagnosis of abdominal with newer technology. The beginnings of a
pain, workable systems that could supplant the global solution to this substantial obstacle to
mind of the generalist are still the dream of the networking progress is in sight: the technology
many developers pursuing this goal, rather than that enables the Internet an international net-
a reality available to doctors in their consulting work of telephonically linked personal com-
rooms now. puters also enables the establishment of intran-
In therapeutics, computerised prescribing ets, in which individual servers (computers dedi-
systems still require the doctor to make the cated to serving information to other computers)
decision about treatment, but facilitate the pro- act as repositories of published data, which
cess of writing, issuing, and recording the pre- other users on the network may browse as
scription. In so doing, the system can provide necessary in a client-server environment.
automated checks, warning if necessary about Systems that support this process are still in
allergies, potential drug interactions, or dosing early stages of development, but the key con-
errors. The built-in safety that this process ceptualisations are in place. Developments over
offers is enhanced by the superior legibility of the next 510 years will centre on the electronic
the script that ensues, reducing the potential for patient record available to the clinician on an
error when the medicine is dispensed by the integrated clinical workstation. The clinical
nurse or the pharmacist. workstation in essence a personal computer
Success in these individual applications con- networked to the hospital or practice system
tinues to drive development, although the pro- will enable the clinician to record clinical data
cess has its critics, who are not slow to point to and diagnoses, automate the ordering of
the lengthier consultations that arise when a investigations and the collection of the results,
computer is present in the consulting room and and facilitate referral and communication
its distracting effect on communication with between the many professionals and depart-
the patient. ments involved in any individual patients
Underlying these many software applications care.
lies the ubiquitous personal computer more Once data is digitised and that includes
powerful today than its mainframe predecessor text, statistical tables, graphs, illustrations and
of only 20 years ago combined with network- radiological images, etc. it may be as freely
ing technology that enables interconnection networked globally as locally. Consultations in
and the sharing of data. As in essence the doc- which live video and sound transmissions are
tors role involves the acquisition, manipulation the bonds of the doctor-patient relationship
and application of information from the indi- (the techniques of telemedicine) are already
vidual patient, and from the body of medical reality, and have proved particularly convenient
knowledge great excitement surrounds the and cost-effective in linking the patient and the
development of open systems that allow differ- generalist to specialists in remote areas with low
ent software and hardware platforms to inter- population density.
act. Many problems remain to be solved, not As with written personal medical records,
 Ingestion 367

confidentiality of personal medical information medical education in print or electronic media.

on computers is essential. Computerised data Consent is said to be informed when patients
are covered by the Data Protection Act 1984. are fully aware of the consequences and risks of
This stipulates that data must: the procedure in question. For example, doctors
be obtained and processed fairly and lawfully. and other health professionals should tell
be held only for specified lawful purposes. patients of the complications of a treatment and
not be used in a manner incompatible with
those purposes.
the likelihood of its success. They should make
sure that the patients understand the informa-
only be recorded where necessary for these tion given; patients should be given the
purposes. opportunity to ask questions and, where
be accurate and up to date. appropriate, immediate relatives should be
not be stored longer than necessary. involved in the process. Doctors are often
be made available to the patient on request. inclined to highlight the benefits of a treatment,
be protected by appropriate security and
backup procedures.
while downplaying the risks, but the General
Medical Council in the United Kingdom has
As these problems are solved, concerns about shown its willingness to discipline doctors who
privacy and confidentiality arise. While paper go beyond the consent that they were given by
records were often only confidential by default, patients.
the potential for breaches of security in com- Although the precise limits will remain dif-
puterised networks is much graver. External ficult to define in some settings, informed con- I
breaches of the system by hackers are one ser- sent should be obtained from patients in
ious concern, but internal breaches by author- accordance with guidelines from professional
ised users making unauthorised use of the data medical organisations. Patients or close relatives
are a much greater risk in practice. Governing should consult the local NHS authorities or
network security so that clinical users have help-groups if they are dissatisfied with their
access on a need-to-know basis is a difficult doctors explanations.
business: the software tools to enable this
encryption, and anonymisation (ensuring that Infrared Radiation
clinical information about patients is anonym- The band of electromagnetic radiation which
ous to prevent confidential information about has a longer wavelength than that of the red in
them leaking out) of data collected for man- the visible spectrum. Infrared radiation is used
agement and research processes exist in the in the special photographic process essential to
technical domain but remain a complex con- THERMOGRAPHY. Its property of transmitting
undrum for solution in the real world. radiant heat has made infrared radiation invalu-
The mushroom growth of websites covering able in PHYSIOTHERAPY, where it warms tissues,
myriad subjects has, of course, included health soothes pain and increases the local circulation.
information. This ranges from clinical details
on individual diseases to facts about medical Infundibulum
organisations and institutes, patient support A funnel-shaped passage. The word is used spe-
groups, etc. Some of this information contains cifically to describe the hollow conical stalk that
comments and advice from orthodox and links the HYPOTHALAMUS to the posterior lobe
unorthodox practitioners. This open access to of the PITUITARY GLAND.
health information has been of great benefit to
patients and health professionals. But web Infusion
browsers should be aware that not all the med- The intravenous or subcutaneous injection of
ical information, including suggested treat- one of a variety of therapeutic solutions, such as
ments, has been subject to PEER REVIEW, as is saline, glucose, or gum acacia, in the treatment
the case with most medical articles in recog- of severe DEHYDRATION, HYPOGLYCAEMIA, or
nised medical journals. other plasma electrolyte imbalance. Blood infu-
sions may be given in cases of severe ANAEMIA
Informed Consent for example, after heavy bleeding. Infusions
Patients rights are a growing concern for doc- may be given in intermittent amounts of
tors and patients. A controversial aspect of their around 570 ml (1 pint) at a time, or alter-
clinical relationship is consent: doctors need natively by continuous drip-feed over several
signed agreement from patients before carrying hours.
out operations or procedures; before entering
patients in clinical trials; and before publishing Ingestion
clinical details or photographs of patients for (1) The act of taking fluid, food, or medicine
 368 Ingrowing Toenail

into the stomach. (2) The way in which a tations, tremor and restlessness are uncommon
phagocytic cell surrounds and absorbs foreign with these, more specific preparations. In
substances such as bacteria in the blood. patients who get insufficient relief from the
beta-adrenoreceptor agonist, the drug ipratro-
Ingrowing Toenail pium bromide is worth adding. Salmeterol is a
The sides of the toenail curve downwards, longer-acting choice for twice-daily administra-
resulting in inflammation of the skin next to tion: it is not intended for the relief of acute
the nail which spreads to the base of the nail. attacks, for which shorter-acting beta2 stimu-
The skin and nail base may become painful and lants such as salbutamol should be used. Salm-
badly infected. If antibiotics and local dressing eterol should be added to existing corticosteroid
do not cure the condition, surgery to remove therapy (see CORTICOSTEROIDS), rather than
part of the nail will be required. replacing it.
Patients must be taught carefully and
Inguinal Hernia observed while using their inhalers. It is
An extrusion of the abdominal PERITONEUM, important for them to realise that if the aerosol
sometimes containing a loop of bowel, through no longer gives more than slight transient relief,
natural openings in the region of either groin they should not increase the dose but seek med-
(see HERNIA). ical help.
I Inguinal Region Inhalation
The groin that area of the body where the A method of applying drugs in a finely divided
lower part of the abdomen meets the upper or gaseous state, so that, when breathed in, they
thigh. The inguinal ligaments extend on each may come into contact with the nose, throat
side from the superior spines of the iliac bones and lungs. There are two chief means by which
to the pubic bone. It is also called Pouparts drugs are mingled with the air and so taken in
ligament (see diagram of ABDOMEN). by breathing: these are traditional steam inhal-
ations, and modern aerosol devices which
Inhalants deliver a fine spray direct into the mouth. (See
Substances that can be inhaled into the body INHALANTS; INHALER.)
through the lungs. They may be delivered in
traditional form dissolved in hot water and Inhaler
inhaled in the steam, or as an aerosol a sus- A mechanism for administering a drug in the
pension of very small liquid or solid particles in form of a powder or aerosol. mainly used by
the air. The latter are now usually delivered by patients with ASTHMA. Inhalers are basically of
devices in which the aerosol is kept under pres- two types: aerosol, and dry-powder inhaler. The
sure in a small hand-held cylinder and delivered former delivers the drug as an aerosol spray
in required doses by a release mechanism. when the patient presses the top of the canister
containing the drug; the latter works by putting
Aerosols Asthmatic patients (see ASTHMA) a drug capsule in the end of the chamber and,
find aerosol devices to be of value in controlling when the patient presses the top, the capsule
their attacks. They provide an effective and is pierced and the drug released. A variety of
convenient way of applying drugs directly to spacing devices are available to use with pres-
the bronchi, thus reducing the risks of surised (aerosol) inhalers, providing metered
unwanted effects accompanying SYSTEMIC doses. The space introduced between the
therapy. BRONCHODILATOR aerosols contain inhaler and the mouth reduces the velocity of
either a beta-sympathomimetic agent or iprat- the aerosol and thus the impact it has on the
ropium bromide, which is an ANTICHOLINER- oropharynx. More time is therefore allowed for
GIC drug. evaporation of the propellant, with a greater
ISOPRENALINE was the first compound to be concentration of drug particles being inhaled.
widely used as an aerosol. It did however stimu- Inhalers with larger spacing devices and a one-
late beta1 receptors in the heart as well as beta2 way valve are very effective and particularly use-
receptors in the bronchi, and so produced pal- ful for children and patients needing higher
pitations and even dangerous cardiac arrhyth- doses of the drug. (See INHALANTS;
mias. Newer beta-adrenoceptor agonists are NEBULISERS.)
specific for the beta2 receptors and thus have a
greater safety margin. They include SAL- Inheritance
BUTAMOL, TERBUTALINE, rimiterol, fenoterol The transfer of characteristics, traits and dis-
and reproterol. Unwanted effects such as palpi- orders from parents to children by means of
 Insecticides 369

GENES carried in the CHROMOSOMES of the Inotropic

germ cells. (See GERM CELL; GENETIC CODE; Adjective describing anything that affects the
GENETIC DISORDERS.) force of muscle contraction. It is usually applied
to the heart muscle; an inotrope such as
Inhibition DIGOXIN is a drug that improves its contraction.
Inhibition means arrest or restraint of some Beta-blocker drugs such as PROPRANOLOL
process effected by nervous influence. The term HYDROCHLORIDE have negative inotropic
is applied to the action of certain inhibitory properties.
nerves: for example, the vagus nerve which con-
tains fibres that inhibit or control the action of Inpatient
the heart. The term is also applied generally to A person who requires a hospital bed for
the mental processes by which instinctive but investigation or treatment.
undesirable actions are checked by a process of
self-control. Inquest
An official inquiry conducted by a CORONER
Injections into the cause of an individuals death. The
An injection is the introduction of a substance coroner is a judicial officer who, when a death is
into the body using a syringe and an attached sudden, unexpected or occurs in suspicious cir-
needle. Injections may be given under the skin cumstances, considers the results of medical
(subcutaneous), via a vein (intravenous), deep and legal investigation and, sitting with a jury I
into a muscle (intramuscular), or into the fluid or on his or her own, makes the conclusions
surrounding the spinal cord (intrathecal). public. He/she has wide powers, and, in deaths
of uncertain cause, no official death certificate
Inner Ear can be issued without his or her approval. A
This comprises three fluid-filled chambers, or coroner may be legally or medically qualified
labyrinths, situated in the bony temporal area (or both). In Scotland the comparable officer is
that are concerned with identifying a persons the procurator fiscal.
position in space. Each chamber lies in a differ- Insanity
ent plane, and movement of fluid within it is See MENTAL ILLNESS.
picked up by sensory cells that transmit the
information to the brain. Disease or damage to Insecticides
the inner ear upsets the sense of balance and Substances which kill insects. Since the dis-
causes vertigo. MOTION TRAVEL SICKNESS is covery of the insecticidal properties of DDT
caused by the inner ear being unable to (see DICHLORODIPHENYL TRICHLOROETHANE)
accommodate the changes in position resulting in 1940, a steady stream of new ones has
from motion. (See EAR.) been introduced. Their combined use has
played an outstanding part in international
Innervation public health campaigns, such as that of the
The nerve supply to a tissue, organ or part of World Health Organisation for the eradica-
the body. It carries motor impulses to and sens- tion of MALARIA.
ory impulses away from the part. Unfortunately, insects are liable to become
resistant to insecticides, just as bacteria are
Inoculation liable to become resistant to antibiotics, and it
The process by which infective material is is for this reason that so much research work is
brought into the system through a small wound being devoted to the discovery of new ones.
in the skin or in a mucous membrane. Many Researchers are also exploring new methods,
infectious diseases are contracted by accidental such as releasing sexually sterile insects into the
inoculation of microbes as is blood- natural population.
poisoning (see SEPTICAEMIA). Inoculation is The useful effects of insecticides must be set
now used as a preventive measure against many against increasing evidence that the indis-
infectious diseases. (See also VACCINE.) criminate use of some of these potent prepar-
ations is having an adverse effect not only
Inositol upon human beings, but also upon the eco-
A sugar compound that is one constituent of systems. Some, such as DDT the use of which
some phospholipids (see LIPID) found in cells. is now banned in the UK are very stable com-
It is found in many foods but, although some- pounds that enter the food chain and may
times classified as a VITAMIN, it is not a vital ultimately be lethal to many animals, including
part of the human diet. birds and fishes.
 370 Insemination

Insemination The hormone acts by enabling the muscles

The ejaculation of SEMEN in the VAGINA in the and other tissues requiring sugar for their activ-
act of sexual intercourse. In ARTIFICIAL INSEM- ity to take up this substance from the blood. All
INATION the semen is placed there by the use of insulin preparations are to a greater or lesser
an instrument. (See also ASSISTED CONCEPTION.) extent immunogenic in humans, but immuno-
logical resistance to insulin action is
Insight uncommon.
A persons knowledge of him or herself. The Previously available in three strengths, of 20,
description is especially relevant to a persons 40, and 80 units per millilitre (U/ml), these
realisation that he or she has psychological dif- have now largely been replaced by a standard
ficulties. Thus, someone with a psychosis (see strength of 100 U/ml (U100). Numerous dif-
MENTAL ILLNESS) lacks insight. Insight also ferent insulin preparations are listed; these dif-
refers to an individuals concept of his or her fer in their speed of onset and duration of
personality and problems. action, and hence vary in their suitability for
individual patients.
Insomnia Insulin is inactivated by gastrointestinal
See SLEEP, DISORDERS OF; HYPNOTICS. enzymes and is therefore generally given by
subcutaneous injection, usually into the upper
I Inspissation arms, thighs, buttocks, or abdomen. Some insu-
The process of the drying or thickening of lins are also available in cartridge form, which
fluids or excretions by evaporation. may be administered by injection devices
(pens). The absorption may vary from differ-
Institutionalisation ent sites and with strenuous activity. About 25
A condition brought about by a prolonged stay per cent of diabetics require insulin treatment:
in an impersonal institution. The individual most children from the onset, and all patients
becomes apathetic and listless as a result of presenting with ketoacidosis. Insulin is also
inadequate stimulation in an uninteresting often needed by those with a rapid onset of
environment. The condition can occur in men- symptoms such as weight loss, weakness, and
tal institutions or long-stay nursing homes; the sometimes vomiting, often associated with
affected person loses the ability to make any ketonuria.
decisions and becomes pathetic and increas- The aim of treatment is to maintain good
ingly dependent on others. control of blood glucose concentration, while
avoiding severe HYPOGLYCAEMIA; this is usu-
Insufflation ally achieved by a regimen of preprandial
Insufflation means the blowing of powder or injections of short-acting insulin (often with a
vapour into a cavity, especially through the air bedtime injection of long-acting insulin). Insu-
passages, for the treatment of disease. lin may also be given by continuous sub-
cutaneous infusion with an infusion pump.
Insulin This technique has many disadvantages:
A POLYPEPTIDE hormone (see HORMONES) pro- patients must be well motivated and able to
duced in the PANCREAS by the beta cells of the monitor their own blood glucose, with access
ISLETS OF LANGERHANS. It plays a key role in to expert advice both day and night; it is
the bodys regulation of CARBOHYDRATE, FAT, therefore rarely used.
and PROTEIN, and its deficiency leads to DIA- Hypoglycaemia is a potential hazard for
BETES MELLITUS. Diabetic patients are many patients converting from porcine to
described as type 1 (insulin dependent), or type human insulin, because human insulin may
2 (non-insulin dependent), although many of result in them being unaware of classical hypo-
the latter may need insulin later on, in order to glycaemic warning symptoms. Drivers must be
maintain good control. particularly careful, and individuals may be for-
Insulin is extracted mainly from pork pan- bidden to drive if they have frequent or severe
creas and purified by crystallisation; it may be hypoglycaemic attacks. For this reason, insur-
made biosynthetically by recombinant DNA ance companies should be warned, and dia-
technology using Escherichia coli, or semisyn- betics should after taking appropriate medical
thetically by enzymatic modification of porcine advice either return to porcine insulin or con-
insulin to produce human insulin. The latter is sider stopping driving.
the form now generally used, although some
patients find it unsuitable and have to return to Insulinase
porcine insulin. An ENZYME occurring in body tissues, such as
 Intensive Therapy Unit (ITU) 371

the kidney and liver, that breaks down INSULIN MYELITIS in an outbreak of this potentially fatal
in the body. disease in Denmark in 1952. Doctors reduced
to 40 per cent, the 90 per cent mortality in
Insulinoma patients receiving respiratory support with the
A tumour in the beta cells in the Islets of Lang- traditional cuirass ventilator by using the new
erhans in the PANCREAS that produces insulin. technique. They achieved this with a combin-
Symptoms of HYPOGLYCAEMIA occur. Treat- ation of manual positive-pressure ventilation
ment is surgical removal or oral administration provided through a TRACHEOSTOMY by medical
of diazoxide. students, and by looking after the patients in a
specific area of the hospital, allowing the neces-
Insulin Shock sary staffing and equipment resources to be
A disorder in which the body produces excess concentrated in one place.
INSULIN, which then reduces the amount of The principle of one-to-one, 24-hours-a-day
glucose in the blood (HYPOGLYCAEMIA). Treat- care for seriously ill patients has been widely
ment is with glucose or GLUCAGON. Untreated, adopted and developed for the initial treatment
the patient goes into a COMA and dies. of many patients with life-threatening condi-
tions. Thus, severely injured patients those
Integument with serious medical conditions such as coron-
Another name for skin. The term is also used ary thrombosis or who have undergone major
for a layer or membrane surrounding any of the surgery, and individuals suffering from poten- I
bodys organs. tially lethal toxic affects of poisons are treated
in an INTENSIVE THERAPY UNIT (ITU). Patients
Intelligence Quotient (IQ) whose respiratory or circulatory systems have
This is the ratio between the mental age and failed benefit especially by being intensively
chronological age multiplied by 100. Thus, if a treated. Most patients, especially post-operative
boy of 10 years of age is found to have a mental ones, leave intensive care when their condition
age of 12 years, his IQ will be 120. On the has been stabilised, usually after 24 or 48 hours.
other hand, if he is found to have a mental age Some, however, need support for several weeks
of 8 years, his IQ will be 80. or even months. Since 1952, intensive medicine
The mental age is established by various has become a valued specialty and a demanding
tests, the most widely used of which are the one because of the range of skills needed by the
Stanford-Binet Scale, the Wechsler Adult Intel- doctors and nurses manning the ITUs.
ligence Scale, and the Mill Hill Vocabulary
Test. Intensive Therapy Unit (ITU)
Average intelligence is represented by an IQ Sometimes called an intensive care unit, this is a
of 100, with a range of 85 to 115. For practical hospital unit in which seriously ill patients
purposes it is taken that the intellectual level undergo resuscitation, monitoring and treat-
reached by the average 15-year-old is indis- ment. The units are staffed by doctors and
tinguishable from that of an adult. nurses trained in INTENSIVE CARE MEDICINE,
and patients receive 24-hour, one-to-one care
Intelligence Test with continuous monitoring of their condition
A standardised procedure of mental assessment with highly specialised electronic equipment
to determine an individuals intellectual ability. that assesses vital body functions such as heart
The result is produced as a score termed the rate, respiration, blood pressure, temperature
INTELLIGENCE QUOTIENT (IQ). The Wechsler and blood chemistry. The average ITU in Brit-
Adult Intelligence Scale (WAIS) and one for ain has four to six beds, although units in larger
children, the Wechsler Intelligence Scale for hospitals, especially those dealing with tertiary-
Children (WICS), are commonly used, as is the care referrals for example, neurosurgical or
Stanford-Binet Scale. Assessments are made for organ transplant cases are bigger, but 15 beds
educational purposes and to help in the diag- is usually the maximum. Annual throughput of
noses of people with possible mental retard- patients ranges from fewer than 200 to more
ation or intellectual deterioration. than 1,500 patients a year. As well as general
ITUs, specialty units are provided for neonatal,
Intensive Care Medicine paediatric, cardiothoracic and neurological
The origin of this important branch of medi- patients in regional centres. The UK has 12
cine lies in the effective use of positive-pressure per cent of its hospital beds allocated to inten-
VENTILATION of the lungs to treat respiratory sive care, a figure far below the average of 20 per
breathing failure in patients affected by POLIO- cent provided in the United States. Thus
 372 Intercostal

patients undergoing intensive care in the UK cytes. They interact to control the immune
are usually more seriously ill than those in the response of cells and also participate in HAEMO-
US. This is reflected in the shortage of available POIESIS. There are seven varieties, interleukins 1
ITU beds in Britain, especially in the winter. to 7. For example, interleukin 1 is produced as a
(See CORONARY CARE UNIT (CCU); HIGH result of inflammation and stimulates the pro-
DEPENDENCY UNIT.) liferation of T and B lymphocytes, enhancing
the immune response by stimulating other
Intercostal lymphocytes and activating dormant T cells.
The term applied to the nerves, vessels and Interleukin 2 has anti-cancer effects as it is able
muscles that lie between the ribs, as well as to to activate T lymphocytes to become killer cells
diseases affecting these structures. which destroy foreign antigens (see ANTIGEN)
such as cancer cells, and this anti-cancer effect is
Interferon being developed for clinical use. The remaining
It has been known for many years that one interleukins have a range of properties in cell
VIRUS will interfere with the growth of another. growth and differentiation.
In 1957, UK research workers isolated the fac-
tor that was responsible for the phenomenon, Intermediate Care
giving it the name of interferon. There are now Described by the UK government as a bridge
known to be three human interferons. They are between hospital and home to speed discharge
I glycoproteins and are released from cells from acute care and provide recovery and
infected with virus or exposed to stimuli which rehabilitation services, this concept was a key
mimic virus infection. They not only inhibit element in the NHS Plan: plan for investment; a
the growth of viruses; they also inhibit the plan for reform, published in 2000. The gov-
growth and reduplication of cells, and this is the ernment sees cottage hospitals, private nursing
basis for their investigation as a means of treat- homes, and domiciliary and community set-
ing cancer. Hitherto the major difficulty has tings as providing the heart of the proposed
been obtaining sufficient supplies of interferon, intermediate-care sector. Also in the plan, how-
but methods have now been evolved which ever, is the warning that the NHS would meet
promise to provide adequate amounts of it. The the costs only of nursing care for nursing-home
most promising of these is by means of what is residents: personal care would in future be
known as genetic engineering, or manipulation, charged for. (In Scotland the NHS funds
whereby a portion of DNA from interferon is personal-care costs.) The change in England
inserted into the micro-organism known as would alter the principles on which the NHS
Escherichia coli (see ESCHERICHIA) which thus was founded in 1948 that all citizens would
becomes a source of almost unlimited amounts receive a universal, comprehensive service
of interferon as it can be grown so easily. funded by the government. New care trusts will
Interferon alfa previously termed leucocyte commission and deliver both primary and
interferon or lymphoblastoid interferon has community health care as well as social care.
some antitumour effect in some solid tumours The trusts will hold unified, capped budgets
and lymphomas. It is also used to treat HEPA- and they will define what is NHS care and what
TITIS B and C (chronic variety). Various side- is social care. The social-care elements will be
effects include suppression of MYELOBLAST subject to the charging policies of local author-
production. Interferon beta previously ities. Of the 160,000 or so nursing-home resi-
termed fibroblast interferon is used (under dents in England, under 10 per cent have their
restricted conditions in the UK) to treat care fully funded by the NHS. The funding
patients with relapsing, remitting MULTIPLE future of this 10 per cent is uncertain, as will be
SCLEROSIS (MS), and interferon beta-16 is the personal-care funding of 270,000 NHS
licensed for use in patients with the secondary patients expected to transfer from hospital into
progressive type of this disorder. The use of intermediate care each year. It is too early to say
interferon, which has a range of side-effects, what effect these changes will have on a vulner-
should be recommended by a neurologist. able section of the population. While the prin-
ciple of using intermediate care to free expen-
Interleukins sive hospital beds is sensible, the uncertainties
Interleukins are lymphokines that is, poly- over funding and the grey area between the
peptides produced by activated lymphocytes. need for nursing and/or residential care will be
They are involved in signalling between cells of a worry for elderly people, especially those of
the immune system (see IMMUNITY) and are limited means. (Legislation to implement the
released by several cell types, including lympho- governments planned changes to the NHS was
 Intersexuality 373

going through Parliament as this text was going Internet

to press, so modifications to them are possible.) Access to medical information via the Internet
is widespread in some populations, often serv-
Intermittent ing more patients than doctors. In addition to
A term applied to fevers which continue for a the huge variety of information available,
time, subside completely and then return again. patients can share experiences via electronic
The name is also used in connection with a discussion groups, or obtain e-mail advice on a
pulse in which occasional heartbeats are not felt, fee-for-service basis. Some professional organ-
in consequence of irregular action of the heart. isations and journals provide free access to
information, and the Internet can be a useful
Intermittent Claudication resource for medical practitioners and
A condition occurring in middle-aged and eld- researchers. Concerns have arisen about the
erly people, which is characterised by pain in growth in electronic medical information: some
the legs after walking a certain distance. The believe that patients who have unlimited access
pain is relieved by resting for a short time. It is to information via the Internet will be less likely
due to arteriosclerosis (see ARTERIES, DISEASES to tolerate health-care rationing or will demand
OF) of the arteries to the leg, which results in treatments that may be inappropriate in their
inadequate blood supply to the muscles. Drugs individual circumstances. Other criticisms
usually have little effect in easing the pain, but relate to the quality and accuracy of the infor-
useful preventive measures are to stop smoking, mation provided, potential breaches of patient
I
reduce weight (if overweight), and to take as CONFIDENTIALITY, and the risk of increased
much exercise as possible within the limits accusations of medical negligence (see also
imposed by the pain. ETHICS).

Intermittent Self- Internode

Catheterisation The length of the AXON (of a nerve cell) that is
A technique in which a patient (of either sex) covered with a MYELIN sheath. The nodes of
inserts a disposable catheter (see CATHETERS) Ranvier, which have no myelin sheath, separate
through the URETHRA into the bladder to the internodes. (See also NERVE.)
empty it of urine. It is increasingly used to
manage patients with chronic retention of Intersexuality
urine, or whose bladders do not empty properly Intersexuality is a state of indeterminate sexual-
usually the result of neurological disorder ity of an individual, and may present in many
affecting the bladder (neuropathic bladder). (See different forms. A characteristic is that only one
URINARY BLADDER, DISEASES OF.) type of gonad testis or ovary is present; in a
HERMAPHRODITE both types are present. Inter-
Intern sexuality may be due to a fault in the genetic
An American term for a doctor-in-training who mechanism of sex determination as early as
carries out his or her duties and learns in conception, or to later errors in sexual differen-
hospital, usually spending some of his/her time tiation of the embryo and fetus, or after birth.
living there. The terms preferred in the UK are Some cases may result from abnormal metabol-
house officer or senior house officer (SHO). ism of the sex hormones, or may be drug-
induced (for example, women given androgens
International Classification of [see ANDROGEN] or PROGESTERONE for
Disease (ICD) repeated miscarriages may give birth to girls
A World Health Organisation classification of with some genital VIRILISATION). Abnormal-
all known diseases and syndromes. The diseases ities of the sex chromosomes may be associated
are divided according to system (respiratory, with delayed (or failure of ) sexual develop-
renal, cardiac, etc.) or type (accidents, malig- ment, so that the individual shows some of
nant growth, etc.). Each of them is given a the characteristics (often underdeveloped) of
three-digit number to facilitate computerisa- both sexes. Some of the more common
tion. This classification allows mortality and presentations of the condition include
morbidity rates to be compared nationally and HYPOGONADISM, CRYPTORCHIDISM, and pri-
regionally. A revised ICD is published every mary AMENORRHOEA.
ten years; a similar classification is being Intersexuality inevitably leads to consider-
developed for impairments, disabilities and able psychological disturbance as the child
handicaps. grows up. It is therefore important to reach an
early decision as to the childs sex or at least,
 374 Interstitial

the sex that he or she is to be brought up as. Interstitial Cells

Surgical or hormonal means should then be Also called Leydig cells, these cells are scattered
employed, when appropriate, to develop the between the SEMINIFEROUS TUBULES of the tes-
attributes of that sex and diminish those of tis (see TESTICLE). LUTEINISING HORMONE from
the other, together with psychological the anterior PITUITARY GLAND stimulates the
counselling. interstitial cells to produce androgens, or male
hormones.
Interstitial
Interstitial is a term applied to indifferent tissue Intertrigo
set among the proper active tissue of an organ. Inflammation between two skin surfaces in
It is generally of a supporting character and contact, typically in the toe clefts, axillae, under
formed of fibrous tissue. The term is also the breasts or in the anogenital folds. Heat,
applied to the fluid always present in this in a friction and obesity are aggravating factors.
small amount, and to diseases which specially Secondary fungal or bacterial infection with
affect this tissue, such as interstitial keratitis. CANDIDA or bacteria is common.

Lateral view of prolapsed intervertebral disc.

 Intestine 375

Interventional Radiology (1012 inches), into which the ducts of the

The use of radiology (see X-RAYS) to enable doc- liver and pancreas open; the jejunum, compris-
tors to carry out diagnostic or treatment pro- ing the next 2427 metres (89 feet); and
cedures under direct radiological vision. This finally the ileum, which at its lower end opens
X-ray procedure is used in MINIMALLY INVASIVE into the large intestine.
SURGERY (MIS) for example, ANGIOPLASTY, the The large intestine begins in the lower part of
removal of stones from the kidney (see KIDNEYS, the abdomen on the right side. The first part is
DISEASES OF), and the observation of obstruc- known as the caecum, and into this opens the
tions in the bile ducts (percutaneous CHOL- appendix vermiformis. The appendix is a small
ANGIOGRAPHY). (See also magnetic resonance tube, closed at one end and about the thickness
imaging MRI.) of a pencil, anything from 2 to 20 cm (average 9
cm) in length, which has much the same struc-
Intervention Study ture as the rest of the intestine. (See APPENDI-
Comparison of outcomes between two or more CITIS.) The caecum continues into the colon.
groups of patients who have been intentionally This is subdivided into: the ascending colon
given different treatments or preventative which ascends through the right flank to
measures, for example, diets. The subjects in beneath the liver; the transverse colon which
the trial should be randomly allocated to the crosses the upper part of the abdomen to the
groups, with patients in one group called con- left side; and the descending colon which bends
trols receiving no active treatment. If possible, downwards through the left flank into the pel- I
neither patients nor doctors participating in a vis where it becomes the sigmoid colon. The
study should know which patients are receiving last part of the large intestine is known as the
what treatment (double blind study/trial). Fur- rectum, which passes straight down through
thermore, groups should exchange treatments the back part of the pelvis, to open to the
after a prearranged time (crossover study/trial). exterior through the anus.
(See CLINICAL TRIALS; RANDOMISED CON-
TROLLED TRIAL.) Structure The intestine, both small and
large, consists of four coats, which vary slightly
Intervertebral Disc in structure and arrangement at different
The fibrous disc that acts as a cushion between points but are broadly the same throughout the
the bony vertebrae (see SPINAL COLUMN), enabl- entire length of the bowel. On the inner sur-
ing them to rotate and bend one on another. face there is a mucous membrane; outside this
The disc tends to degenerate with age and may is a loose submucous coat, in which blood ves-
get ruptured and displaced prolapsed or sels run; next comes a muscular coat in two
slipped disc as a result of sudden strenuous layers; and finally a tough, thin peritoneal
action. Prolapsed disc occurs mainly in the membrane.
lower back; it is more common in men than in MUCOUS COAT The interior of the bowel is
women, and in the 3040 age group. completely lined by a single layer of pillar-like
cells placed side by side. The surface is increased
Intestine by countless ridges with deep furrows thickly
All the alimentary canal beyond below the studded with short hair-like processes called
stomach. In it, most DIGESTION is carried on, villi. As blood and lymph vessels run up to the
and through its walls all the food material is end of these villi, the digested food passing
absorbed into the blood and lymph streams. slowly down the intestine is brought into close
The length of the intestine in humans is about relation with the blood circulation. Between the
859 metres (2830 feet), and it takes the form bases of the villi are little openings, each of
of one continuous tube suspended in loops in which leads into a simple, tubular gland which
the abdominal cavity. produces a digestive fluid. In the small and large
intestines, many cells are devoted to the pro-
Divisions The intestine is divided into small duction of mucus for lubricating the passage of
intestine and large intestine. The former the food. A large number of minute masses,
extends from the stomach onwards for 65 called lymph follicles, similar in structure to the
metres (22 feet) or thereabouts. The large intes- tonsils are scattered over the inner surface of the
tine is the second part of the tube, and though intestine. The large intestine is bare both of
shorter (about 18 metres [6 feet] long) is much ridges and of villi.
wider than the small intestine. The latter is SUBMUCOUS COAT Loose connective tissue
divided rather arbitrarily into three parts: the which allows the mucous membrane to play
duodenum, consisting of the first 2530 cm freely over the muscular coat. The blood vessels
 376 Intestine, Diseases of

and lymphatic vessels which absorb the food in ulcers, which rupture with the ordinary move-
the villi pour their contents into a network of ments of the bowels. Whatever the cause, the
large vessels lying in this coat. symptoms are much the same.
MUSCULAR COAT The muscle in the small
intestine is arranged in two layers, in the outer Symptoms The contents of the bowel pass
of which all the fibres run lengthwise with the out through the perforation into the peritoneal
bowel, whilst in the inner they pass circularly cavity, and set up a general peritonitis. In con-
round it. sequence, the abdomen is painful, and after a
PERITONEAL COAT This forms the outer cov- few hours becomes extremely tender to the
ering for almost the whole intestine except touch. The abdomen swells, particularly in its
parts of the duodenum and of the large intes- upper part, owing to gas having passed also into
tine. It is a tough, fibrous membrane, covered the cavity. Fever and vomiting develop and the
upon its outer surface with a smooth layer of person passes into a state of circulatory collapse
cells. or SHOCK. Such a condition may be fatal if not
properly treated.
Intestine, Diseases of
The principal signs of trouble which has its ori- Treatment All food should be withheld and
gin in the intestine consist of pain somewhere the patient given intravenous fluids to resusci-
about the abdomen, sometimes vomiting, and tate them and then to maintain their hydration
I irregular bowel movements: constipation, diar- and electrolyte balance. An operation is
rhoea or alternating bouts of these. urgently necessary, the abdomen being opened
Several diseases and conditions are treated in the middle line, the perforated portion of
under separate headings. (See APPENDICITIS; bowel found, the perforation stitched up, and
CHOLERA; COLITIS; CONSTIPATION; CROHNS appropriate antibiotics given.
DISEASE; DIARRHOEA; DYSENTERY; ENTERIC
FEVER; HAEMORRHOIDS; HERNIA; INFLAMMA- Obstruction means a stoppage to the pas-
TORY BOWEL DISEASE (IBD); ILEITIS; INTUS- sage down the intestine of partially digested
SUSCEPTION; IRRITABLE BOWEL SYNDROME food. Obstruction may be acute, when it comes
(IBS); PERITONITIS; RECTUM, DISEASES OF; on suddenly with intense symptoms; or it may
ULCERATIVE COLITIS.) be chronic, when the obstructing cause grad-
ually increases and the bowel becomes slowly
Inflammation of the outer surface is called more narrow until it closes altogether; or sub-
peritonitis, a serious disease. That of the acute, when obstruction comes and goes until it
inner surface is known generally as enteritis, ends in an acute attack. In chronic cases the
inflammation of special parts receiving the symptoms are milder in degree and more
names of colitis, appendicitis, irritable bowel prolonged.
syndrome (IBS) and inflammatory bowel dis-
ease (IBD). Enteritis may form the chief symp- Causes Obstruction may be due to causes
tom of certain infective diseases: for example in outside the bowel altogether, for example, the
typhoid fever (see ENTERIC FEVER), cholera and pressure of tumours in neighbouring organs,
dysentery. It may be acute, although not con- the twisting around the bowel of bands pro-
nected with any definite organism, when, if duced by former peritonitis, or even the twist-
severe, it is a very serious condition, particularly ing of a coil of intestine around itself so as to
in young children. Or it may be chronic, espe- cause a kink in its wall. Chronic causes of the
cially as the result of dysentery, and then consti- obstruction may exist in the wall of the bowel
tutes a less serious if very troublesome itself: for example, a tumour, or the contracting
complaint. scar of an old ulcer. The condition of INTUS-
SUSCEPTION, where part of the bowel passes
Perforation of the bowel may take place as inside of the part beneath it, in the same way as
the result either of injury or of disease. Stabs one turns the finger of a glove outside in, causes
and other wounds which penetrate the abdo- obstruction and other symptoms. Bowel within
men may damage the bowel, and severe blows a hernia may become obstructed when the her-
or crushes may tear it without any external nia strangulates. Finally some body, such as a
wound. Ulceration, as in typhoid fever, or, concretion, or the stone of some large fruit, or
more rarely, in TUBERCULOSIS, may cause an even a mass of hardened faeces, may become
opening in the bowel-wall also. Again, when the jammed within the bowel and stop up its
bowel is greatly distended above an obstruction, passage.
faecal material may accumulate and produce
 Intracytoplasmic Sperm Injection 377

Symptoms There are four chief symptoms: supportive tube or stent passed into each
pain, vomiting, constipation and swelling of the affected artery can restore the blood supply.
abdomen. The stent has a HEPARIN coating to stop blood
clots from forming. Since it was first performed
Treatment As a rule the surgeon opens the in 1987, intracoronary stents have cut the
abdomen, finds the obstruction and relieves it reblockage rate from one in three patients who
or if possible removes it altogether. It may be have had coronary ANGIOPLASTY to fewer than
necessary to form a COLOSTOMY or ILEOSTOMY one in ten in cases where a stent was used with
as a temporary or permanent measure in severe angioplasty.
cases.
Intracranial
Tumours are rare in the small intestine and Intracranial is the term applied to structures,
usually benign. They are relatively common in diseases, etc. contained in or rising within the
the large intestine and are usually cancerous. head.
The most common site is the rectum. Cancer of
the intestine is a disease of older people; it is the Intracranial Pressure
second most common cancer (after breast can- This is the pressure that is maintained by the
cer) in women in the United Kingdom, and the brain tissue, intracellular and extracellular fluid,
third most common (after lung and prostate) in cerebrospinal fluid and blood. An increase in
men. Around 25,000 cases of cancer of the large intracranial pressure may occur as a result of I
intestine occur in the UK annually, about 65 inflammation, injury, haemorrhage, or tumour
per cent of which are in the colon. A history of in the brain tissue as well as of some congenital
altered bowel habit, in the form of increasing conditions. The pressure is measured by lumbar
constipation or diarrhoea, or an alternation of puncture in which a syringe attached to a
these, or of bleeding from the anus, in a middle- mamometer (pressure-measuring device) is
aged person is an indication for taking medical inserted into the cerebrospinal fluid surround-
advice. If the condition is cancer, then the ing the lower part of the spinal cord. Where
sooner it is investigated and treated, the better continuous pressure monitoring is necessary, an
the result. in-dwelling device can be implanted into a
cerebral ventricle. Normal pressure is around 10
Intima mm of mercury (Hg), with the acceptable
The innermost coat lining the arteries and the upper limit being 25 mm Hg.
veins.
Intracytoplasmic Sperm
Intolerance Injection
An adverse reaction of a patient to a drug or Intracytoplasmic sperm injection (ICSI) is the
treatment. (See ADVERSE REACTIONS TO most significant therapeutic advance in male
DRUGS.) INFERTILITY treatment in the past 30 years. The
technique is used when in vitro fertilisation
Intoxication (IVF see under ASSISTED CONCEPTION) is not
A term applied to states of poisoning. The poi- possible because the man has very few, motile,
son may be some chemical substance intro- normal sperm (see SPERMATOZOON), or when
duced from outside, for example, ALCOHOL; or previous attempts at IVF have not produced a
it may be due to the products of bacterial fertilised EMBRYO. ICSI requires a single sperm
action, the bacteria either being introduced which is injected directly into the cytoplasm of
from outside or developing within the body. an egg previously retrieved from the woman.
The term autointoxication is applied in the Once fertilised, the embryo is transferred to her
latter case. UTERUS. For men with no sperm in the semen,
it may be possible to retrieve sperm by needle
Intra- aspiration of the EPIDIDYMIS under local anaes-
Prefix indicating inside or within. For example, thetic (see ANAESTHESIA). Other techniques
intracellular: within a cell; intra-articular: involve microsurgical retrieval from the epi-
within a joint. didymis or TESTICLE under a general anaes-
thetic. Potential complications include scrotal
Intracoronary Artery Stenting pain, bruising, HAEMATOMA formation and
A narrowed or blocked coronary artery (see infection. ICSI and surgical sperm-retrieval
ARTERIES) can compromise the blood supply to require extensive training and expertise and is
the heart muscle (see HEART, DISEASES OF). A currently available in only a few selected
 378 Intrathecal

infertility units. Safety concerns relate to a

higher-than-expected rate of abnormalities in
the SEX CHROMOSOMES after ICSI, and also the
potential risk of transmitting paternal genetic
defects in the Y chromosome to sons born after
ICSI.

Intrathecal
Intrathecal means within the membranes or
meninges which envelop the SPINAL CORD. The
intrathecal space, between the arachnoid and
the pia mater, contains the CEREBROSPINAL
FLUID (see INTRACRANIAL PRESSURE).

Intrauterine Contraceptive
Device (IUCD)
A mechanical device, commonly a coil, inserted
into the UTERUS to prevent CONCEPTION,
probably by interfering with the implantation
I of the EMBRYO. For many women, IUCDs are Position of intravenous needle inserted into vein
an effective and acceptable form of contracep- on back of hand for administration of intravenous
tion, although only about 10 per cent of fluid or blood transfusion.
women in the UK use them. The devices are of
various shapes and made of plastic or copper; Intrinsic Factor
most have a string that passes through the cer- Secreted in the lining of the stomach, this factor
vix and rests in the vagina. is one of the GLYCOPROTEINS, and is essential
About one-third of women have adverse for the absorption into the bloodstream of
effects as the result of IUCD use: common ones vitamin B12 (see APPENDIX 5: VITAMINS).
are backache and heavy menstrual bleeding (see Absence of intrinsic factor causes a deficiency of
MENSTRUATION). The frequency of unwanted this essential vitamin, which in turn causes
pregnancies is about 2 per 100 women-years of PERNICIOUS ANAEMIA.
use. (See CONTRACEPTION.)

Intrauterine Insemination Intromission

A method of helping CONCEPTION to occur The introduction of one organ or part into
when a man is infertile (see INFERTILITY) another. An example is the insertion of the erect
because his sperm (see SPERMATOZOON) cannot penis into the vagina during copulation.
penetrate either the cervical mucus at the
entrance of the UTERUS or the barriers that sur- Introspection
round the OVUM. The sperm, often treated The observation of ones own thoughts or feel-
chemically beforehand to increase motility, are ings. The term is generally applied to this pro-
injected directly into the uterus via the VAGINA. cess when it occurs to an abnormal extent in
association with MELANCHOLIA.
Intravenous
A term which means inside a vein. An intraven- Introversion
ous injection is one that is given into a vein. (1) In physical terms, to turn a hollow structure
Blood transfusions are given intravenously, as into itself for example, a length of the intes-
are other infusions of fluid. tine may enter the succeeding portion, also
known as INTUSSUSCEPTION.
Intravenous Pyelogram (2) A psychological term to describe what hap-
(Urogram) pens when an individual is more interested in
A procedure for getting X-ray pictures of the his or her inner world than in what is happen-
URINARY TRACT. A radio-opaque medium is ing around in the real world. An INTROVERT
injected into a vein and, when it is excreted by tends to have few friends and prefers to persist
the kidneys, the substance can be identified on in activities that they have started. Karl Jung (see
X-rays. Any abnormalities in structure or for- JUNGIAN ANALYSIS) described introversion as a
eign bodies such as calculi are outlined by the persons tendency to distance him or herself
dye (see KIDNEYS, DISEASES OF). from others; to have philosophical interests;
 Iodides 379

and to have reactions that are reserved and spread of cancer into normal, nearby tissues or
defensive. organs.

Introvert In Vitro
Physically it means turning inside out. Psycho- A term commonly used in medical research and
logically, the term refers to an individual whose experimental biology. Literally in a glass, it
character looks inwards on him or herself and refers to observations made outside the body:
who may also be obsessive and have few friends. for example, on the action of drugs on bacteria.
(See INTROVERSION.) The opposite term is IN VIVO, which refers to
observations of processes in the body.
Intubation
A procedure consisting in the introduction, In Vitro Fertilisation (IVF)
through the mouth or nose into the larynx, of a Fertilisation of the egg (ovum) outside the
tube designed to keep the air passage open at body. The fertilised ovum is then incubated
this point. until the blastocyst stage develops, when it is
implanted into the UTERUS. The procedure was
Intuition developed in Britain and the first successful in
The immediate understanding of a situation by vitro baby, a girl, was born in 1978. IVF is used
someone without the customary mental process when a woman has blocked FALLOPIAN TUBES
of reasoning. or when the sperm and ovum are unable to fuse I
in the reproductive tract. Hormone treatment
Intussusception results in the potential mothers producing sev-
A form of obstruction of the bowels in which eral mature ova, some of which are removed
part of the INTESTINE enters within that part from the ovary using a LAPAROSCOPE and fertil-
immediately beneath it. This can best be under- ised with her partners semen. (See ASSISTED
stood by observing what takes place in the fin- CONCEPTION.)
gers of a tightly fitting glove as they turn
outside-in when the glove is pulled off the In Vivo
hand. Mostly, the condition affects infants. A Latin term to describe biological events that
Often it occurs during the course of a viral take place inside the bodies of living organisms.
infection or a mild attack of gastroenteritis, or it
may be that swelling of lymphoid tissue in the Involucrum
gut provokes the event. The point at which it The sheath of new bone which is formed round
most often occurs is the junction between the a piece of dead bone in, for example,
small and the large intestines, the former pass- OSTEOMYELITIS.
ing within the latter. The symptoms are those
of intestinal obstruction in general (see INTES- Involuntary Muscle
TINE, DISEASES OF Obstruction), and in add- Muscle that does not operate under a persons
ition there is often a discharge of blood-stained conscious control. Involuntary muscle also
mucus from the bowel. Unless the symptoms called smooth muscle, because the cells do not
rapidly subside, when it may be assumed that contain the striations that occur in VOLUNTARY
the bowel has righted itself, treatment consists MUSCLE is found in blood vessels, the heart,
of either hydrostatic reduction by means of a stomach, and intestines. (See PARASYMPATHETIC
barium or air ENEMA, or an operation. At oper- NERVOUS SYSTEM.)
ation the intussusception is either reduced or, if
this not possible, the obstructed part is cut out Involution
and the ends of the intestine then stitched The process of change whereby the UTERUS
together. If treated adequately and in time, the returns to its resting size after parturition
mortality is now reduced to around 1 per cent. (birth). The term is also applied to any retro-
The condition may recur in about 5 per cent of grade biological change, as in senility (see
patients. AGEING).

In Utero Iodides
Literally in the UTERUS and used to refer to Salts of iodine, those which are especially used
events occurring to a baby before birth. in medicine being the iodide of potassium and
iodide of sodium. Iodides are excreted in the
Invasion mucus secretions, as well as in the urine, saliva
The entry of bacteria into the body; the and sweat, and have an action in liquefying the
 380 Iodine

mucus secretion of the bronchial tree. They are (see EXPECTORANTS) given in the treatment of
therefore used in EXPECTORANTS. They are also BRONCHITIS. (See POISONS.)
used to assist in providing a supply of iodine in
patients with goitre, or in individuals who live Ipratropium
in an area where goitre is liable to occur because An ANTICHOLINERGIC, BRONCHODILATOR
of a deficiency of IODINE in the drinking water. drug, given by aerosol inhalation to treat
They may be given in the form of iodised salt. ASTHMA, BRONCHITIS and RHINITIS.
(See THYROID GLAND, DISEASES OF Goitre.)
IQ
Iodine See INTELLIGENCE QUOTIENT (IQ).
A non-metallic element which is found largely
in seaweed. The body contains about 30 mg, Iridectomy
largely concentrated in the THYROID GLAND The operation by which a hole is made in the
where it is used to synthesise thyroid hormones. iris of the EYE as, for example, in the treat-
Iodine has a highly irritating action and, when ment of GLAUCOMA or as part of CATARACT
applied to the skin, stains the latter dark brown surgery.
and causes it to peel off in flakes, while intern-
ally it is a violent irritant poison in large doses. Iris
Externally iodine is used as an antiseptic. Its See EYE.
I drawback is that it is fixed by protein, which
reduces its antiseptic efficiency in open wounds. Iritis
Its main use in this sphere therefore is for steril- See UVEITIS.
ising the unbroken skin, as before an operation.
Radioactive iodine is used for diagnosing and Iron
treating disease of the thyroid gland. A metal which is an essential constituent of the
red blood corpuscles, where it is present in the
Ion Atom form of HAEMOGLOBIN. It is also present in
An atom (or a collection of atoms) that has an muscle as MYOGLOBIN, and in certain respira-
electrical charge. Positive atoms are cations, tory pigments which are essential to the life of
negative ones are anions. Calcium, hydrogen, many tissues in the body. Iron is absorbed prin-
potassium and sodium are positive ions. Nega- cipally in the upper part of the small intestine.
tive ones include bicarbonate chloride and It is then stored: mainly in the liver; to a lesser
phosphate. All the substances are critical to the extent in the spleen and kidneys, where it is
bodys physiological activities. available, when required, for use in the bone
marrow to form the haemoglobin in red blood
Ion Exchange Resins corpuscles. The daily iron requirement of an
Synthetic organic substances, capable of adult is 1520 milligrams. This requirement is
exchanging ions cationic or anionic from increased during pregnancy.
the contents of the intestine. Originally used in
the prevention of OEDEMA, they have been Uses The main use of iron is in the treatment
superseded in this role by the modern DIURET- of iron-deficiency anaemias (See ANAEMIA.)
ICS, and are now used chiefly in the treatment Iron preparations sometimes cause irritation of
of HYPERKALAEMIA. They are usually taken by the gastrointestinal tract, and should therefore
mouth or as an ENEMA. always be taken after meals. They sometimes
produce a tendency towards constipation.
Ionisation Whenever possible, iron preparations should
Ionisation means the breaking up of a substance be given by mouth; if PARENTERAL administra-
in solution into its constituent. tion is clinically necessary because of mal-
absorption, a suitable preparation is iron
Ipecacuanha sorbitol injection given intramuscularly. Most
The root of Cephalis ipecacuanha, a Brazilian patients respond successfully to oral iron
shrub. It contains an alkaloid, emetine, which preparations.
acts as an irritant when brought into contact
with the interior of the stomach, producing Irradiation
vomiting. Formerly used to induce vomiting The use of naturally occurring isotopes, or arti-
among young children after poisoning and if ficially produced X-rays, in the killing of
still alert, but now of uncertain value, it was tumour cells. The amount of radiation is the
used in many traditional expectorant mixtures adsorbed dose; the SI unit is the gray (Gy).
 Ischaemic Stroke 381

Different tumours seem to be particularly sensi- treatment. If this fails, treatment should be dir-
tive to radiation; radiotherapy plays an import- ected at the major symptoms. Several months of
ant role in the management of germ-cell the antidepressant amitriptyline (see ANTI-
tumours (SEMINOMA; TERATOMA) and lymph- DEPRESSANT DRUGS) may benefit patients with
omas (see LYMPHOMA). Many head and neck intractable symptoms, given at a dose lower
tumours, gynaecological cancers, and localised than that used to treat depression. The majority
prostate and bladder cancers are curable with of patients follow a relapsing/remitting course,
radiotherapy. It may be used to reduce the pain with episodes provoked by stressful events in
for example, from bone metastases. their daily lives. (See also INTESTINE, DISEASES
OF.)
Unwanted effects Generalised: lethargy,
loss of appetite. Skin: ERYTHEMA, dry des- Irritant
quamation with itching, moist desquamation. Any substance that produces irritation in a tis-
Patients should keep the treated area(s) dry and sue. Examples are: stinging nettles, which cause
clean and avoid soap, antiseptic mouthwashes, pain and swelling; certain insect bites or stings
smoking and spicy food if possible. (See ISO- which do the same; and anti riot gases such as
TOPE; RADIATION SICKNESS; RADIOTHERAPY). CS gas, which cause the eyes to water and pro-
voke coughing. Regular, unprotected handling
Irrigation of certain substances for example, oil can
Irrigation is the method of washing-out irritate the skin and cause DERMATITIS. Some I
wounds, or cavities of the body, like the bladder people are more sensitive than others to the
and bowels. (See DOUCHE; ENEMA.) effect of irritants; sometimes an irritant will
produce an allergic reaction (see ALLERGY) and
Irritable Bowel Syndrome (IBS) in serious cases ANAPHYLAXIS, which may
A disorder of the intestinal tract that affects its require medical treatment.
motility and causes abdominal distension and
irregular defaecation. Traditional, but now dis- Ischaemia
carded, names have been spastic or irritable Bloodlessness of a part of the body, due to con-
colon. The disease affects around 20 per cent of traction, spasm, constriction or blocking (by
the general population but in most it is no more EMBOLUS or by THROMBUS) of the arteries: for
than a minor nuisance. The causes are not fully example, of the heart.
understood, but it is generally believed that
symptoms develop in response to psychological Ischaemic Heart Disease
factors, changed gastrointestinal motility, or See HEART, DISEASES OF.
altered visceral sensation. About 50 per cent of
patients meet criteria for a psychiatric diagnosis. Ischaemic Stroke
Anxiety, depression, neurosis, panic attacks, A STROKE that occurs when the flow of blood to
acute disease are among possible triggering fac- a part of the brain is interrupted by a partial or
tors. Some patients have diarrhoea, others are complete THROMBOSIS of the supplying artery
constipated, and some alternate between the or ARTERIES, or by a clot of blood that has
two. Many have increased sensitivity to disten- detached itself from elsewhere in the circulatory
sion of the intestine. Dietary factors such as system for instance, a deep vein thrombosis
intolerance to dairy products and wheat are (DVT) and blocked a cerebral artery. Stroke is
apparent in certain patients. the second most common cause of death
Common features of IBS include: worldwide. Its treatment is difficult and preven-
abdominal distension. tion is best targeted at those who are at the
altered bowel habit. highest absolute risk of stroke, because such
colicky lower abdominal pain, eased by people are likely to derive the greatest benefit.
defaecation. They generally have a history of occlusive vascu-
mucous discharge from rectum. lar diseases such as previous ischaemic stroke or
feelings of incomplete defaecation.
Investigations usually produce normal
a transient ischaemic attack (TIA), coronary
heart disease (see HEART, DISEASES OF) or PER-
results. Positive diagnosis in people under 40 is IPHERAL VASCULAR DISEASE. In the UK strokes
usually straightforward. In older patients, how- affect about 200 people per 100,000 popula-
ever, barium ENEMA, X-rays and COLONOS- tion annually, with the incidence rising sharply
COPY should be done to exclude colorectal after the age of 55. At the age of 70 the inci-
cancer. dence is around 15 people per 1,000 of popula-
Reassurance is the initial and often effective tion; at 80 the figure is double that.
 382 Ischiorectal Abscess

About 80 per cent of patients survive an Iso-Immunisation

acute stroke and they are at risk of a further The IMMUNISATION of a person by an ANTIGEN
episode within a few weeks and months; they do not have but which is present in other
about 10 per cent in the first year and 5 per people. For example, a rhesus-negative mother
cent a year after that. HYPERTENSION, smok- does not carry the rhesus antigen. If she carries a
ing, HYPERLIPIDAEMIA and raised concentra- rhesus-positive baby, passage of the rhesus anti-
tion of blood sugar, along with OBESITY, are gen from the baby into the mothers circulation
significant pointers to further strokes and pre- may cause her to be iso-immunised. Her
ventive steps to reduce these factors are immune system (see IMMUNITY) may then pro-
worthwhile, although the reduction in risk is duce ANTIBODIES to the rhesus antigen. When
hard to assess. Even so, the affected person she next becomes pregnant, if the baby is again
should stop smoking, greatly reduce alcohol rhesus positive, the mother will produce large
intake, check for and have treated diabetes, amounts of anti-Rh antibodies which can enter
reduce weight and exercise regularly. In any the fetal circulation and cause its blood cells to
case, a diet rich in fresh fruit and vegetables break up. (See HAEMOLYTIC DISEASE OF THE
and low in fat and salt, exercise and the avoid- NEWBORN; BLOOD GROUPS.)
ance of smoking may reduce the risk of hav-
ing a first stroke. Isolation
The evidence is inconclusive that patients This is important when treating patients with
I with ischaemic stroke should be treated with serious infection or whose immune systems
antihypertensives. Furthermore, neither the (see IMMUNITY) are severely compromised by
starting blood pressure nor the best drug regi- illness or radio- or chemotherapy. The pro-
men or its starting time are generally agreed. cedure also protects staff caring for infectious
Studies on the most effective methods of pre- patients. (See INCUBATION; INFECTION;
venting and treating stroke are continuing; QUARANTINE.)
meanwhile available evidence suggests that an
active approach to prevention of primary and Isoleucine
secondary hypertension will benefit patients One of the essential AMINO ACIDS, which are
and usually be cost-effective. fundamental components of all proteins. It
cannot be synthesised by the body and so must
Ischiorectal Abscess be obtained from the diet.
An ABSCESS arising in the space between the
RECTUM and ischial bone (see ISCHIUM) and Isometric
often resulting in a FISTULA. It may occur spon- Of similar measurement. Isometric exercises are
taneously or be secondary to an anal fissure, based on the isometric contraction of the
thrombosed HAEMORRHOIDS or other anal dis- muscles. Fibres are provoked into working by
ease. The disorder is painful and usually pushing or pulling an immovable object, but
accompanied by fever. Treatment is by a com- this technique prevents them from shortening
bination of antibiotics and surgery. in length. These exercises improve a persons
fitness and builds up his or her muscle strength.
Ischium
Ischium is the bone which forms the lower and Isoniazid
hinder part of the pelvis. It bears the weight of One of the anti-tuberculous drugs. It has the
the body in sitting. advantages of being relatively non-toxic and
of being active when taken by mouth.
Ishiharas Test Unfortunately, like streptomycin, it may render
A test for colour vision, introduced by a Japa- the Mycobacterium tuberculosis resistant to its
nese doctor, comprising several plates with action. This tendency to produce resistance is
round dots of different colours and sizes. It is considerably reduced if it is given in conjunc-
also the name of a type of blood test for tion with RIFAMPICIN and PYRAZINAMIDE.
SYPHILIS.
Isoprenaline
Islets of Langerhans An INOTROPIC sympathomimetic drug which is
Groups of specialised cells distributed through- used as a short-term emergency treatment of
out the PANCREAS, that produce three hor- heart block or severe BRADYCARDIA. (See HEART,
mones: INSULIN, GLUCAGON, and DISEASES OF.)
SOMATOSTATIN.
 Isotope 383

Isotonic If the investigation necessitates tracing the

A term applied to solutions which have the path of the material through the body by means
same power of diffusion as one another. An iso- of external counting over the body surface, it is
tonic solution used in medicine is one which obviously essential to use an isotope that emits
can be mixed with body fluids without causing gamma radiation or positrons. If, however, only
any disturbance. An isotonic saline solution for measurements on blood sample or excreta are
injection into the blood, so that it may possess required, it is possible to use pure beta emitters.
the same osmotic pressure (see OSMOSIS) as the Whole-body counters measure the total radio-
blood SERUM, is one of 09 per cent strength activity in the body, and these are of great value
that is, containing 9 grams of sodium chloride in absorption studies.
to 1 litre of water. This is also known as normal Moving images can provide information on
or physiological salt solution. An isotonic solu- body functions such as the movements of the
tion of bicarbonate of soda for injection into heart, blood flow, bile flow in the liver, and
the blood is one of 135 per cent strength in urine in the kidneys. The development of
water. An isotonic solution of glucose for injec- COMPUTED TOMOGRAPHY or CT scanning has
tion into the blood is one of 5 per cent strength replaced radionuclide scanning for some
in water. imaging procedures.
Solutions which are weaker, or stronger, than Five main groups of diagnostic uses may be
the fluids of the body with which they are defined:
intended to be mixed are known as hypotonic (1) METABOLIC STUDIES The use of radioactive
I
and hypertonic, respectively. materials in metabolic studies is based on the
fundamental property that all isotopes of an
Isotope element are chemically identical. The radio-
This is a form of a chemical element with the active isotope is used as a true isotope tracer
same chemical properties as other forms, but that is, when introduced into the body (in
which has a different atomic mass. It contains whatever form) it behaves in the same way as
an identical number of positively charged par- the inactive element. For example, isotopes of
ticles called protons, in the nucleus, giving it iodine are used to measure thyroid function (see
the same atomic number, but the numbers of THYROID GLAND), and isotopes of calcium
neutrons differ. A radioactive isotope, or radio- enable kinetic studies of bone formation and
nuclide, is one that decays into other isotopes, destruction to be performed.
and in doing so emits alpha, beta or gamma (2) ABSORPTION AND DISTRIBUTION STUDIES
radiation. The fate of labelled substances given by mouth
can be followed to assess their absorption, util-
Applications of radionuclides to isation and excretion. In most of these studies
diagnosis The use of radionuclides in diag- the isotope is a true isotope tracer. For example,
nosis is based on the fact that it is possible to tag iron absorption can be measured with radio-
many of the substances normally present in the active iron; vitamin B12 absorption may be
body with a radioactive label. Certain synthetic investigated with vitamin B12 tagged with
radioactive elements, such as technetium, can radioactive cobalt.
also be used. Because it is possible to detect (3) BODY COMPOSITION BY DILUTION STUDIES
minute quantities of radioactive material, only By introducing an isotope into a compartment,
very small doses are needed, making the pro- such as the blood or extracellular space, it is
cedure a safe one. Furthermore the body pool of possible to measure the volume of that
the material is therefore not appreciably altered, compartment by determining the dilution of
and metabolism is not disturbed. Thus in stud- radioactivity when equilibrium has been
ies of iodine metabolism the ratio of radioactive reached.
atoms administered to stable atoms in the body (4) PHYSICAL TRACING STUDIES In this type of
pool is of the order of 1:1,000 million. By study the isotope is not necessarily used as a
measuring radioactivity in the body, in blood true isotopic tracer. In other words, it does not
samples, or in the excreta it is possible to gain trace the path of the corresponding inactive iso-
information about the fate of the labelled sub- tope. For example, xenon-133 is used in meas-
stance, and hence of the chemically identical urements of blood flow in muscles, and in lung-
inactive material. Therefore it is theoretically function studies; krypton-85 is used to detect
possible to trace the absorption, distribution intracardiac shunts (abnormal blood flows in
and excretion of any substance normally pres- the heart). Neither of these elements is nor-
ent in the body, provided that it can be tagged mally present in the body. The survival of
with a suitable radioactive label. ERYTHROCYTES may be followed and the organ
 384 Itch

of sequestration revealed by labelling them with peak voltage of 34 million volts. (See
radioactive chromium. RADIOTHERAPY.)
(5) SCANNING OF ORGANS AND TISSUES Scan-
ning is a technique which is used to deter- Itch
mine the distribution of radioactive isotopes Itch is a popular name for SCABIES.
within the body or within one particular organ.
In the conventional scanner, the radiation Itching
detector which is a scintillation counter See PRURITUS.
sees only a small cross-sectional area of the
body at a time. The activity seen at each -Itis
point is registered, and a map of the activity A suffix added to the name of an organ to sig-
seen over the scanned area is recorded. Various nify any INFLAMMATION of that organ.
methods of presentation have been used, and
the recently improved display systems present ITP
the information gathered by the scanner more See IDIOPATHIC THROMBOCYTOPENIC PURPURA
effectively. More recent developments are sta- (ITP).
tionary detectors such as the gamma camera,
auto-fluoroscope, and other devices which can Itraconazole
view the whole of the area simultaneously. A triazole antifungal drug taken orally for
I Thus when selective concentration of an iso- oropharyngeal and vulvovaginal CANDIDA,
tope in a tissue occurs, it is possible to exam- PITYRIASIS versicolor, and tinea corporis and
ine the distribution of that isotope by means pedis (see under RINGWORM). It is also used for
of scanning. A toxic nodule in the thyroid systemic fungal infections such as ASPERGIL-
may be identified by its selective concentra- LOSIS, candidiasis and cryptococcosis where
tion of iodine-131. Areas of absent function other fungicidal drugs have not worked. Itraco-
on the radioactive scan (cold areas) suggest nazole is metabolised in the liver so should not
the presence of tumours, abscesses, and similar be given to patients who have or have had liver
lesions. Iodine-131 may be used to localise disease. The drug can be given as maintenance
tumours of the thyroid, and chlormerodrin treatment of AIDS (see AIDS/HIV) patients to
labelled with mercury-197 to delineate prevent resurgence of underlying fungal disease
tumours of the kidneys. Of even greater prac- to which they are vulnerable. (See FUNGAL AND
tical application is the localising of brain YEAST INFECTIONS.)
tumours with human serum albumin labelled
with iodine-131 or with radioactive IUCD (IUD)
technetium. Abbreviation for an intrauterine contraceptive
device (coil). It acts mechanically to prevent
Treatment Radioactive isotopes are also used conception, but the coil is not suitable for all
in medical treatment. The overactivity of the women and has a failure rate of 23 per cent (see
thyroid gland in thyrotoxicosis can be treated CONTRACEPTION).
by the ingestion of radioactive iodine. The
ingested iodine is taken up by the thyroid gland IUS
where local irradiation of the gland takes place, Intrauterine system a hormonal contraceptive
reducing its activity. Radioactive phosphorus is device that is placed in the UTERUS. It is a long-
used in the treatment of polycythemia rubra term reversible method of CONTRACEPTION.
vera. It is largely taken up in bone as this is the
main source of body phosphate, and irradiation IVF
of the bone marrow results, controlling the See IN VITRO FERTILISATION (IVF); ASSISTED
overactivity that is characteristic of poly- CONCEPTION.
cythaemia rubra vera (see under POLYCYTHAE-
MIA). In cobalt teletherapy the isotope cobalt 60 Ivory
is used to deliver 1213 million volt radiation Ivory, or dentine, is the hard material which
which is equivalent to X-rays generated at a forms the chief bulk of the TEETH.
 is the symptom that attracts notice. Indigestion,

J nausea, poor appetite and general malaise are

other symptoms. The skin may itch, and the
faeces are pale because of the absence of bile.

Treatment The essential step is to treat the

underlying cause if possible: for instance, gall-
Jacksonian Epilepsy stones, if these be the cause of the jaundice.
See EPILEPSY. Comprehensive laboratory investigations are
usually required, and supportive measures are
Jaundice needed. (See also LIVER, DISEASES OF.).
Jaundice is a yellow discoloration of the skin
due to the deposition of BILE pigment in its Jaw
deeper layers. It is the main sign of several dis- The name applied to the bones that carry the
orders of the liver and biliary system. Many teeth. The two upper jaw-bones, the maxillae,
babies develop jaundice soon after birth are firmly fixed to the other bones of the face.
because of the accumulation of BILIRUBIN (yel- The lower jaw, the mandible, is shaped some-
low bile pigment) in the blood. In most, this is what like a horseshoe, and, after the first year of
due to liver immaturity and soon disappears, life, consists of a single bone. It forms a hinge-
but a serious disorder, HAEMOLYTIC DISEASE joint with the squamous part of the temporal
OF THE NEWBORN, is a potentially dangerous bone, immediately in front of the ear. Both
type of neonatal jaundice that requires upper and lower jaw-bones possess deep
treatment. sockets, known as alveoli, which contain the
roots of the teeth. (See DISLOCATIONS; BONE,
Types In adults, three types of jaundice occur. DISORDERS OF; GUMBOIL; TEETH.)
They are all the result of disturbance in the
mechanism by which HAEMOGLOBIN from the Jejunum
breakdown of ageing red blood cells (erythro- Part of the small INTESTINE.
cytes) is not properly processed in the liver.
Normally the breakdown product of this Jelly
haemoglobin bilirubin is made water- See GELATIN.
soluble in the liver and excreted via the bile
ducts into the small intestine, where it colours Jenner, Edward
the stools dark brown. Edward Jenner was an English country prac-
HAEMOLYTIC JAUNDICE In this type, the titioner (17491823). He had noticed that
amount of bilirubin produced is too much for cowpox, which milkmaids caught from cattle,
the liver to deal with, the excess usually being gave these women immunity from the scourge
the result of an abnormal level of haemoglobin of SMALLPOX. In 1796 he transformed this
from the breakdown of blood cells. This observation into the medical technique of VAC-
haemolytic anaemia, as it is known, has several CINATION, innoculating a country boy with
causes (see ANAEMIA). matter from the arm of a milkmaid infected
HEPATOCELLULAR JAUNDICE In this disorder, with cowpox. Despite hostility from some doc-
bilirubin builds up in the blood because liver tors, Parliament voted him a grant of 10,000
cells have been damaged or have died usu- for a society to promote vaccination and the
ally as a result of a viral infection (there are technique spread worldwide, giving benefit to
four types) causing HEPATITIS, or of liver an immense number of people.
failure.
OBSTRUCTIVE JAUNDICE Also called cholestatic Jerk
jaundice, this type is characterised by the A sudden involuntary movement. The term is
inability of bile to be discharged from the liver often used to describe the tendon reflexes.
because the bile ducts are blocked as a result of
gall-stones (see under GALL-BLADDER, DISEASES Joint-Mouse
OF) or a growth. Sometimes the ducts are A popular term for a loose body in a joint. It is
absent (atresia) or have been destroyed in the found especially in the knee. (See JOINTS, DIS-
liver as a result of CIRRHOSIS. EASES OF.)

Symptoms Yellowness, appearing first in the Joint Replacement

whites of the eyes and later over the whole skin, See ARTHROPLASTY.
 386 Joints

Diagram of synovial joints. (Left) A right shoulder-joint (simple synovial) from the front. (Right) Right knee-
joint (synovial with articular disc) from the front.

Joints atmospheric pressure. Where the ends of the

A joint is the articulation point between differ- bones do not quite correspond, a subsidiary
ent parts of the skeleton, whether bone or disc of fibro-cartilage may help to adapt the
cartilage. Joints are divided into those which ends of the bones more perfectly to each other.
are fixed or relatively fixed (fibrous and carti- Larger cavities may be filled by movable pads of
laginous joints), and those which allow free fat under the synovial membrane, giving add-
movement (synovial joints). In the former, itional protection to the joint.
exemplified by the sutures between the bones of
the skull, a layer of cartilage or fibrous tissue lies Varieties After this main division of joints
between the bones, binding them firmly into those which are fixed and those movable,
together. Amphiarthrodial joints, exemplified the movable joints may be further subdivided.
by the joints between the vertebral bodies (see In gliding joints, such as the wrist and ankle,
SPINAL COLUMN), have a thick disc of fibro- the bones have flat surfaces capable of only a
cartilage between the bones. Although the indi- limited amount of movement. In hinge joints,
vidual joint is capable of very little movement, a such as the elbow and knee, movement takes
series of these gives to the spinal column, as a place around one axis. Ball-and-socket joints,
whole, a flexible character. exemplified by the shoulder and hip, allow free
All movable joints involve four structures: movement in any direction. Subsidiary varieties
the bones whose junction forms the joint; a are named according to the shape of the bones
layer of cartilage covering the ends of these, which enter the joint.
making them smooth; a fibrous sheath, the cap-
sule, thickened at various points into bands or Joints, Diseases of
ligaments, which hold the bones together; and, Rheumatism is the colloquial term for non-
finally, the synovial membrane, which lines the specific musculoskeletal symptoms arising in
capsule and produces a synovial fluid, lubricat- the joints, ligaments, tendons and muscles.
ing the movements of the joint. In addition, the Arthritis describes a pathological musculo-
bones are kept in position at the joints by the skeletal disorder. Most common are sprains
various muscles passing over them and by of ligaments, strains of tendons and muscles,
 Joints, Diseases of 387

BURSITIS, TENDINITIS and non-specific back Systemic autoimmune rheumatic

pain (see BACKACHE). diseases (see AUTOIMMUNE DISORDERS).
RHEUMATOID ARTHRITIS (RA) see also main
Osteoarthritis (OA) rarely starts before entry. The most common of these diseases.
40, but by the age of 80 affects 80 per cent of Acute inflammation causes lymphoid synovitis,
the population. There are structural and func- leading to erosion of the cartilage, associated
tional changes in the articular cartilage, as well joints and soft tissues. Fibrosis follows, causing
as changes in the collagenous matrix of ten- deformity. Autoantibodies are common, par-
dons and ligaments. OA is not purely wear ticularly Rheumatoid Factor. A common com-
and tear; various sub-groups have a genetic plication of RA is Sjgrens syndrome, when
component. Early OA may be precipitated by inflammation of the mucosal glands may result
localised alteration in anatomy, such as a frac- in a dry mouth and eyes.
ture or infection of a joint. Reactive new bone SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) and
growth typically occurs, causing sclerosis various overlap syndromes occur, such as sys-
(hardening) beneath the joint, and osteophytes temic sclerosis and dermatomyositis. Autoanti-
outgrowths of bone are characteristic at bodies against nuclear proteins such as DNA
the margins of the joint. The most common lead to deposits of immune complexes and VAS-
sites are the first metatarsal (great toe), spinal CULITIS in various tissues, such as kidney, brain,
facet joints, the knee, the base of the thumb skin and lungs. This may lead to various symp-
and the terminal finger joints (Heberdens toms, and sometimes even to organ failure.
nodes).
OA has a slow but variable course, with Infective arthritis includes: J
periods of pain and low-grade inflammation. SEPTIC ARTHRITIS An uncommon but poten-
Acute inflammation, common in the knee, may tially fatal disease if not diagnosed and treated
result from release of pyrophosphate crystals, early with approriate antibiotics. Common
causing pseudo-gout. causes are TUBERCLE bacilli and staphylococci
(see STAPHYLOCOCCUS). Particularly at risk are
Urate gout results from crystallisation of the elderly and the immunologically vulnerable,
URIC ACID in joints, against a background of such as those under treatment for cancer, or on
hyperuricaemia. This high concentration of CORTICOSTEROIDS or IMMUNOSUPPRESSANT
uric acid in the blood may result from genetic drugs.
and environmental factors, such as excess diet- RHEUMATIC FEVER Now rare in western
ary purines, alcohol or diuretic drugs. countries. Resulting from an immunological
reaction to a streptococcal infection, it is
Inflammatory arthritis is less common characterised by migratory arthritis, rash and
than OA, but potentially much more serious. cardiac involvement.
Several types exist, including:
SPONDYLARTHRITIS This affects younger men, Other infections which may be associated
chiefly involving spinal and leg joints. This with arthritis include rubella (German measles),
may lead to inflammation and eventual ossifi- parvovirus and LYME DISEASE.
cation of the enthesis that is, where the liga-
ments and tendons are inserted into the bone Treatment Septic arthritis is the only type
around joints. This may be associated with dis- that can be cured using antibiotics, while the
orders in other parts of the body: skin inflam- principles of treatment for the others are simi-
mation (PSORIASIS), bowel and genito-urinary lar: to reduce risk factors (such as hyperuric-
inflammation, sometimes resulting in infection aemia); to suppress inflammation; to improve
of the organs (such as dysentery). The syn- function with physiotherapy; and, in the event
dromes most clearly delineated are ankylosing of joint failure, to perform surgical arthroplasty.
spondylitis (see SPINE AND SPINAL CORD, DIS- NON-STEROIDAL ANTI-INFLAMMATORY DRUGS
EASES AND INJURIES OF), psoriatic or colitic (NSAIDS) include aspirin, paracetamol and many
spondylitis, and REITERS SYNDROME. The recently developed ones, such as the proprionic
diagnosis is made clinically and radiologically; acid derivatives IBUPROFEN and naproxen,
no association has been found with autoanti- along with other drugs that have similar proper-
bodies (see AUTOANTIBODY). A particularly ties such as PIROXICAM. They all carry a risk of
clear gene locus, HLA B27, has been identified toxicity, such as renal dysfunction, or gastro-
in ankylosing spondylitis. Psoriasis can be intestinal irritation with haemorrhage. Stronger
associated with a characteristic peripheral suppression of inflammation requires cortico-
arthritis. steroids and CYTOTOXIC drugs such as
 388 Joule

azathioprine or cyclophosphamide. Recent children. Characteristically, the synovial mem-

research promises more specific and less toxic brane of a joint or joints becomes inflamed and
anti-inflammatory drugs, such as the mono- swollen for at leat six weeks (and often very
clonal antibodies like infliximab. An important much longer even years). About 1 in 10,000
treatment for some osteoarthritic joints is surgi- children develop it each year, many of whom
cal replacement of the joints. have certain HLA genetic markers, thought
to be important in determining who gets the
Joule illness. Inflammatory CYTOKINES play a big
The unit of energy in the International System part.
of Units. The official abbreviation is J. 4,1868
J = 1 CALORIE (or kilocalorie). (See also BRITISH Clinical features There are various types.
THERMAL UNIT (BTU); WEIGHTS AND The oligoarthritic type involves 14 joints
MEASURES.) (usually knee or ankle) which become hot,
swollen and painful. One complication is an
Jugular inflammation of the eyes UVEITIS. The condi-
Jugular is a general name for any structure in tion often burns out, but may reappear at any
the neck, but is especially applied to three large time, even years later.
veins, the anterior, external and internal jugular The polyarthritic type is more like RHEUMA-
veins, which convey blood from the head and TOID ARTHRITIS in adults, and the child may
neck regions to the interior of the chest. have persistent symptoms leading to major
joint deformity and crippling.
J Jumpers Knee The systemic type, previously called Stills
See PATELLAR TENDINITIS. disease, presents with a high fever and rash,
enlarged liver, spleen and lymph nodes, and
Jungian Analysis arthritis although the latter may be mild. In
A school of analytical psychology, first some children the illness becomes recurrent; in
described by Carl Gustav Jung in 1913. It others it dies down only to return as
introduced the concepts of introvert and polyarthritis.
extrovert personalities, and developed the the-
ory of the collective unconscious with its Complications These include uveitis, which
archetypes of mans basic psychic nature. In can lead to loss of vision; a failure to thrive;
contrast with Freudian analysis (see FREUDIAN osteoporosis (see under BONE, DISORDERS OF);
THEORY), in Jungian analysis the relationship joint deformity; and psychosocial difficulties.
between therapist and patient is less one-sided
because the therapist is more willing to be active Treatment This includes ANTIPYRETICS and
and to reveal information about him or herself. ANALGESICS, including NON-STEROIDAL ANTI-
(See also PSYCHOANALYSIS.) INFLAMMATORY DRUGS (NSAIDS), intra-articular
steroid injections, anti-tumour necrosis factor
Juvenile Idiopathic Arthritis drugs and steroids.
(JIA) Physiotherapy is vital, and children may need
Previously called juvenile rheumatoid arthritis to wear splints or other orthotic devices to
and juvenile chronic arthritis, this is a set of alleviate deformity and pain. Orthopaedic
related conditions of unknown cause affecting operative procedures may be necessary.
 and toes may peel. The disease may last for sev-

K eral weeks before spontaneously resolving. It is

possible that it is caused by an unusual immune
response to INFECTION (see IMMUNITY).

Arteritis is a common complication and can

result in the development of coronary artery
Kala-Azar aneurysms (see ANEURYSM) in up to 60 per cent
Another name for visceral LEISHMANIASIS. of those affected. These aneurysms and even
myocardial infarction (see HEART, DISEASES OF
Kanamycin Coronary thrombosis) are often detected after
An antibiotic derived from Streptomyces kan- the second week of illness. The disease can be
amyceticus. It is active against a wide range of hard to diagnose as it mimics many childhood
organisms, including Staphylococcus aureus and viral illnesses, especially in its early stages. The
Mycobacterium tuberculosis. incidence in the UK is over 3 per 100,000 chil-
dren under five years of age.
Kaolin
Kaolin, or china clay, is a smooth white powder Treatment Because of the danger of coronary
consisting of natural white aluminium silicate artery disease, prompt treatment is important.
resulting from the decomposition of minerals This is with intravenous IMMUNOGLOBULINS
containing felspar. It is used as a dusting pow- and low-dose aspirin. To be effective, treatment
der for eczema (see DERMATITIS) and other must start in the first week or so of the illness
forms of irritation in the skin. It is also used a time when it is most difficult to diagnose.
internally in cases of diarrhoea. Talc, French
chalk and Fullers earth are similar silicates. Keloid
Kaolin poultice contains kaolin, boric acid, Hard lumpy nodule of the skin due to over-
glycerin and various aromatic substances. growth of fibrous tissue in the dermis. It usually
follows surgical or accidental trauma or burns,
Kaolinosis but, rarely, may complicate acne on the upper
Kaolinosis is a form of PNEUMOCONIOSIS trunk. Most commonly seen in the skin over
caused by the inhaling of clay dust. the sternum, shoulders and upper back; col-
oured people are particularly prone. Injection
Kaposis Sarcoma of corticosteroid into the keloid may cause
Once a very rare disease in western countries, partial resolution. Excision should be avoided.
although more common in Africa, Kaposis sar-
coma is now a feature of AIDS (see AIDS/HIV) Keratin
indeed, its increasing occurrence was one of the The substance of which horn and the surface
first pointers to the development of AIDS. It is layer of the skin are composed.
a condition in which malignant skin tumours
develop, originating from the blood vessels. Keratinisation
The tumours form purple lumps which cus- Deposition of KERATIN in cells, in particular
tomarily start on the feet and ankles, then those in the skin. The cells become horny and
spread up the legs and develop on the arm and flattened and lose their nuclei, forming hair and
hands. In AIDS the sarcoma appears in the nails or hard areas of skin.
respiratory tract and gut, causing serious bleed-
ing. Radiotherapy normally cures mild cases of Keratitis
Kaposis sarcoma, but severely affected patients See under EYE, DISORDERS OF.
will need anti-cancer drugs to check the
tumours growth. Keratomalacia
Softening of the cornea due to a severe vitamin
Kawasaki Disease A deficiency (see EYE, DISORDERS OF).
Also called mucocutaneous lymph node syn-
drome, this disorder of unknown origin occurs Keratoplasty
mainly in children under five and was first See CORNEAL GRAFT.
described in Japan. It is characterised by high
fever, conjunctivitis (see under EYE, DISORDERS Keratosis
OF), skin rashes and swelling of the neck glands. Also known as actinic keratosis; a rough, scaly
After about two weeks the skin from fingertips area on exposed skin caused by chronic solar
 390 Kerion

damage from exposure to sun. The face and EPILEPSY and chronic infections of the urinary
backs of the hands are most commonly affected. tract by Escherichia coli; butter, cream, eggs and
(See also MELANOMA; PHOTODERMATOSES.) fat meat are allowed, whilst sugar, bread and
CRYOTHERAPY is effective, but prevention by other carbohydrates are cut out as far as
appropriate clothing and sun-blocking creams possible.
is a better strategy.
Ketone
Kerion Another name for acetone or dimethyl ketone.
A suppurating form of RINGWORM. The term, ketone bodies, is applied to a group
of substances closely allied to acetone, especially
Kernicterus beta-hydroxybutyric acid and acetoacetic acid.
The staining with BILE of the basal nuclei of the These are produced in the body from imperfect
BRAIN, with toxic degeneration of the nerve oxidation of fats and protein foods, and are
cells, which sometimes occurs in severe found in especially large amount in severe cases
HAEMOLYTIC DISEASE OF THE NEWBORN of DIABETES MELLITUS. Ketonuria is the term
especially if prompt treatment by exchange applied to the presence of these bodies in the
TRANSFUSION has not been carried out. Rare urine.
nowadays, the result is a form of CEREBRAL
PALSY. Ketoprofen
See NON-STEROIDAL ANTI-INFLAMMATORY
Kernigs Sign DRUGS (NSAIDS).
This is found in MENINGITIS. A healthy per-
sons thigh can be bent to a right-angle with the Ketorolac
K body when the knee is straight; in cases of men- A non-opioid analgesic (see ANALGESICS) used in
ingitis the knee cannot be straightened when the short-term management of moderate to
the thigh is bent this way not without causing severe acute post-operative pain. It may be
the patient intense pain. given orally or by intramuscular or intravenous
injection. Gastrointestinal side-effects are
Ketamine common in elderly people, and there are a
An anaesthetic drug, administered by intraven- range of side-effects from ANAPHYLAXIS to
ous or intramuscular injection and used mainly HYPERTENSION, prolonged bleeding time and
in children. The drug has good analgesic prop- liver function changes. Contraindications
erties when used in subanaesthetic doses. One include hypersensitivity to ASPIRIN, ASTHMA,
disadvantage is that when used as an anaes- renal impairment and pregnancy (including
thetic, a high incidence of hallucinations occur. during labour and delivery).
Ketamine is contraindicated in patients with
HYPERTENSION. Ketosis
A condition in which an excessive amount of
Ketoconazole ketones (see KETONE) are produced by the body
An imidazole (see IMIDAZOLES) antifungal drug and these accumulate in the bloodstream. The
available for both oral and topical use. Better affected person becomes drowsy, suffers a head-
absorbed orally than other imidazoles, it also ache, breathes deeply, and may lapse into a
has an anti-androgen effect which may give rise COMA. The condition results from an unbal-
to GYNAECOMASTIA and IMPOTENCE in men. In anced metabolism of fat, which may occur in
view of its potential hepatotoxicity it should DIABETES MELLITUS or starvation.
not be given orally for trivial infections, but
reserved instead for SYSTEMIC fungal infections Keyhole Surgery
(see FUNGAL AND YEAST INFECTIONS). See MINIMALLY INVASIVE SURGERY (MIS).

Ketogenesis Khat
The production of ketones (see KETONE) in the Tender leaves of a shrub that grows in the
body; abnormal ketogenesis may result in Middle East called Catha edelis. The leaves are
KETOSIS. wrapped around betel nuts and chewed: the
result is a feeling of EUPHORIA and an ability to
Ketogenic Diet tolerate harsh living conditions.
This contains such an excess of fats that acetone
and other KETONE bodies appear in the urine. Kidney, Artificial
The diet is sometimes used in the treatment of See DIALYSIS.
 Kidneys, Diseases of 391

Kidneys ous tubules. From these it is finally collected

These are a pair of glands located in the upper into the renal veins and then leaves the kidney.
abdomen close to the spine and embedded in This double circulation (first through the glom-
fat and loose connective tissue. erulus and then around the tubule) allows a
large volume of fluid to be removed from the
Structure Each kidney is about 10 cm long, blood in the glomerulus, the concentrated
6.5 cm wide, 5 cm thick, and weighs around blood passing on to the uriniferous tubule for
140 grams. removal of parts of its solid contents. Other
Adult kidneys have a smooth exterior, arteries come straight from the arches and sup-
enveloped by a tough fibrous coat that is bound ply the medulla direct; the blood from these
to the kidney only by loose fibrous tissue and by passes through another set of capillaries and
a few blood vessels that pass between it and the finally into the renal veins. This circulation is
kidney. The outer margin of the kidney is con- confined purely to the kidney, although small
vex; the inner is concave with a deep depres- connections by both arteries and veins exist
sion, known as the hilum, where the vessels which pass through the capsule and, joining the
enter. The URETER, which conveys URINE to the lumbar vessels, communicate directly with the
URINARY BLADDER, is also joined at this point. aorta.
The ureter is spread out into an expanded,
funnel-like end, known as the pelvis, which fur- Function The kidneys work to separate fluid
ther divides up into little funnels known as the and certain solids from the blood. The glom-
calyces. A vertical section through a kidney (see eruli filter from the blood the non-protein por-
diagram) shows two distinct layers: an outer tion of the plasma around 150200 litres in
one, about 4 mm thick, known as the cortex; 24 hours, 99 per cent of which is reabsorbed on
and an inner one, the medulla, lying closer to passing through the convoluted tubules. K
the hilum. The medulla consists of around a Three main groups of substances are classi-
dozen pyramids arranged side by side, with fied according to their extent of uptake by the
their base on the cortex and their apex project- tubules:
ing into the calyces of the ureter. The apex of (1) SUBSTANCES ACTIVELY REABSORBED These
each pyramid is studded with tiny holes, which include amino acids, glucose, sodium, potas-
are the openings of the microscopic uriniferous sium, calcium, magnesium and chlorine (for
tubes. more information, see under separate entries).
In effect, each pyramid, taken together with (2) SUBSTANCES DIFFUSING THROUGH THE
the portion of cortex lying along its base, is an TUBULAR EPITHELIUM when their concentra-
independent mini-kidney. About 20 small tion in the filtrate exceeds that in the PLASMA,
tubes are on the surface of each pyramid; these, such as UREA, URIC ACID and phosphates.
if traced up into its substance, repeatedly sub- (3) SUBSTANCES NOT RETURNED TO THE
divide so as to form bundles of convoluted BLOOD from the tubular fluid, such as CREAT-
tubules, known as medullary rays, passing up INE, accumulate in kidney failure, resulting in
towards the cortex. One of these may be traced general poisoning known as URAEMIA.
further back, ending, after a tortuous course, in
a small rounded body: the Malpighian cor- Kidneys, Diseases of
puscle or glomerulus (see diagram). Each glom- Diseases affecting the kidneys can be broadly
erulus and its convoluted tubule is known as a classified into congenital and genetic disorders;
nephron, which constitutes the functional unit autoimmune disorders; malfunctions caused by
of the kidney. Each kidney contains around a impaired blood supply; infections; metabolic
million nephrons. disorders; and tumours of the kidney. Outside
After entering the kidney, the renal artery factors may cause functional disturbances for
divides into branches, forming arches where the example, obstruction in the urinary tract pre-
cortex and medulla join. Small vessels come off venting normal urinary flow may result in
these arches and run up through the cortex, hydronephrosis (see below), and the CRUSH
giving off small branches in each direction. SYNDROME, which releases proteins into the
These end in a tuft of capillaries, enclosed in blood as a result of seriously damaged muscles
Bowmans capsule, which forms the end of the (rhabdomyolosis), can result in impaired kid-
uriniferous tubules just described; capillaries ney function. Another outside factor, medicinal
with capsule constitute a glomerulus. drugs, can also be hazardous to the kidney.
After circulating in the glomerulus, the Large quantities of ANALGESICS taken over a
blood leaves by a small vein, which again div- long time damage the kidneys and acute tubu-
ides into capillaries on the walls of the urinifer- lar NECROSIS can result from certain antibiotics.
 392 Kidneys, Diseases of

K
Vertical section through the kidney.

Diagram of renal tubules and blood supply of the

kidney positioned in the cortex and medulla (see
vertical-section diagram).

others experience loin pain associated with

obstruction (renal colic) or due to infection;
fevers; swelling (oedema), usually of the legs but
occasionally including the face and arms; blood
in the urine (haematuria); and excess quantities
of urine (polyuria), including at night (noctu-
ria), due to failure of normal mechanisms in the
kidney for concentrating urine. Patients with
chronic renal failure often have very diffuse
symptoms including nausea and vomiting,
tiredness due to ANAEMIA, shortness of breath,
skin irritation, pins and needles (paraesthesia)
due to damage of the peripheral nerves (per-
Diagram of glomerulus (Malpighian corpuscle). ipheral neuropathy), and eventually (rarely seen
nowadays) clouding of consciousness and
Fortunately the body has two kidneys and, as death.
most people can survive on one, there is a good
functional reserve of kidney tissue. Signs of kidney disease include loin tender-
ness, enlarged kidneys, signs of fluid retention,
Symptoms Many patients with kidney dis- high blood pressure and, in patients with end-
orders do not have any symptoms, even when stage renal failure, pallor, pigmentation and a
the condition is quite advanced. However, variety of neurological signs including absent
 Kidneys, Diseases of 393

reflexes, reduced sensation, and a coarse flap- often in boys than in girls and commonly
ping tremor (asterixis) due to severe disturbance presents as Alports syndrome (familial neph-
of the bodys normal metabolism. ritis with nerve DEAFNESS) with PROTEINURIA,
haematuria, progressing to renal failure and
Renal failure Serious kidney disease may deafness. The cause of the disease lies in an
lead to impairment or failure of the kidneys absence of a specific ANTIGEN in a part of the
ability to filter waste products from the blood glomerulus. The treatment is conservative, with
and excrete them in the urine a process that most patients eventually requiring dialysis or
controls the bodys water and salt balance and transplantation.
helps to maintain a stable blood pressure. Fail-
ure of this process causes URAEMIA an Acute glomerulonephritis is an immune-
increase in urea and other metabolic waste complex disorder due to entrapment within
products as well as other metabolic upsets in glomerular capillaries of ANTIGEN (usually
the blood and tissues, all of which produce derived from B haemolytic streptococci see
varying symptoms. Failure can be sudden or STREPTOCOCCUS) antibody complexes initiat-
develop more slowly (chronic). In the former, ing an acute inflammatory response (see
function usually returns to normal once the IMMUNITY). The disease affects children and
underlying cause has been treated. Chronic young adults, and classically presents with a
failure, however, usually irreparably reduces or sore throat followed two weeks later by a fall in
stops normal function. urine output (oliguria), haematuria, hyperten-
Acute failure commonly results from physio- sion and mildly abnormal renal function. The
logical shock following a bad injury or major disease is self-limiting with 90 per cent of
illness. Serious bleeding or burns can reduce patients spontaneously recovering. Treatment
blood volume and pressure to the point where consists of control of blood pressure, reduced K
blood-supply to the kidney is greatly reduced. fluid and salt intake, and occasional DIURETICS
Acute myocardial infarction (see HEART, DIS- and ANTIBIOTICS.
EASES OF) or pancreatitis (see PANCREAS, DIS-
ORDERS OF) may produce a similar result. A Chronic glomerulonephritis is also due
mismatched blood transfusion can produce to immunological renal problems and is also
acute failure. Obstruction to the urine-flow by a classified by taking a renal biopsy. It may be
stone (calculus) in the urinary tract, a bladder subdivided into various histological varieties as
tumour or an enlarged prostate can also cause determined by renal biospy. Proteinuria of vari-
acute renal failure, as can glomerulonephritis ous degrees is present in all these conditions but
(see below) and the haemolytic-uraemia the clinical presentations vary, as do their
syndrome. treatments. Some resolve spontaneously; others
HYPERTENSION, DIABETES MELLITUS, poly- are treated with steroids or even the cytotoxic
cystic kidney disease (see below) or AMYLOIDO- drug CYCLOPHOSPHAMIDE or the immunosup-
SIS are among conditions that cause chronic pressant cyclosporin. Prognoses are generally
renal failure. Others include stone, tumour, satisfactory but some patients may require
prostatic enlargement and overuse of analgesic renal dialysis or kidney transplantation an
drugs. Chronic failure may eventually lead to operation with a good success rate.
end-stage renal failure, a life-threatening situ-
ation that will need DIALYSIS or a renal trans- Hydronephrosis A chronic disease in
plant (see TRANSPLANTATION). which the kidney becomes greatly distended
with fluid. It is caused by obstruction to the
Familial renal disorders include auto- flow of urine at the pelvi-ureteric junction (see
somal dominant inherited polycystic kidney KIDNEYS Structure). If the ureter is
disease and sex-linked familial nephropathy. obstructed, the ureter proximal to the obstruc-
Polycystic kidney disease is an important cause tion will dilate and pressure will be transmit-
of renal failure in the UK. Patients, usually aged ted back to the kidney to cause hydronephro-
3050, present with HAEMATURIA, loin or sis. Obstruction may occur at the bladder
abdominal discomfort or, rarely, urinary-tract neck or in the urethra itself. Enlargement of
infection, hypertension and enlarged kidneys. the prostate is a common cause of bladder-
Diagnosis is based on ultrasound examination neck obstruction; this would give rise to
of the abdomen. Complications include renal hypertrophy of the bladder muscle and both
failure, hepatic cysts and, rarely, SUBARACH- dilatation of the ureter and hydronephrosis. If
NOID HAEMORRHAGE. No specific treatment is the obstruction is not relieved, progressive
available. Familial nephropathy occurs more destruction of renal tissue will occur. As a
 394 Kinaesthetic Sensations

result of the stagnation of the urine, infection tion. Treatment has undergone considerable
is probable and CYSTITIS and PYELONEPHRITIS change with the introduction of MINIMALLY
may occur. INVASIVE SURGERY (MIS) and the destruction of
stone by sound waves (LITHOTRIPSY).
Impaired blood supply may be the out-
come of diabetes mellitus and physiological Kinaesthetic Sensations
shock, which lowers the blood pressure, also A term used to describe those sensations which
affecting the blood supply. The result can be underlie muscle tension and position of joint
acute tubular necrosis. POLYARTERITIS NODOSA and muscle. These sensations send impulses
and SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) along nerves to the brain, and thus inform it of
may damage the large blood vessels in the kid- the position of the limb in space and of the
ney. Treatment is of the underlying condition. relative position to each other of individual
muscles and muscle-groups and of joints.
Infection of the kidney is called pyelonephri-
tis, a key predisposing factor being obstruction Kinins
of urine flow through the urinary tract. This Substances present in the body which are
causes stagnation and provides a fertile ground powerful VASODILATORS. They also induce pain
for bacterial growth. Acute pyelonephritis is and are probably involved in the production of
more common in women, especially during the headache of MIGRAINE. In addition, they
pregnancy when bladder infection (CYSTITIS) play a part in the production of ALLERGY and
spreads up the ureters to the kidney. Symptoms ANAPHYLAXIS.
are fever, malaise and backache. Antibiotics and
high fluid intake are the most effective treat- Kiss of Life
K ment. Chronic pyelonephritis may start in Emergency mouth-to-mouth resuscitation of
childhood as a result of congenital deformities an unconscious person (see APPENDIX 1: BASIC
that permit urine to flow up from the bladder FIRST AID).
to the kidney (reflux). Persistent reflux leads to
recurrent infections causing permanent damage Klebsiella
to the kidney. Specialist investigations are usu- Gram-negative (see GRAMS STAIN) bacteria
ally required as possible complications include found in the intestinal, respiratory, and uro-
hypertension and kidney failure. genital tracts of people and animals. Varieties of
the bacteria, which are rod-shaped and non-
Tumours of the kidney are fortunately motile, can cause PNEUMONIA and urinary
rare. Non-malignant ones commonly do not infections (see URINARY BLADDER, DISEASES OF).
cause symptoms, and even malignant tumours
(renal cell carcinoma) may be asymptomatic for Kleptomania
many years. As soon as symptoms appear A psychological disorder in which the person
haematuria, back pain, nausea, malaise, some- afflicted has an irresistible compulsion to steal
times secondary growths in the lungs, bones or things, without necessarily having any need for
liver, and weight loss urgent treatment includ- the object stolen.
ing surgery, radiotherapy and chemotherapy is
necessary. This cancer occurs mostly in adults Klinefelters Syndrome
over 40 and has a hereditary element. The The original syndrome described by Klinefelter
prognosis is not good unless diagnosed early. In consisted of GYNAECOMASTIA, testicular ATRO-
young children a rare cancer called nephroblas- PHY and INFERTILITY. Intelligence was
toma (Wilms tumour) can occur; treatment is unimpaired. Patients have been described who
with surgery, radiotherapy and chemotherapy. have associated mental defects and striking tall-
It may grow to a substantial size before being ness of stature, but the only constant feature of
diagnosed. the syndrome is testicular atrophy with result-
ing azoospermia and infertility.
Cystinuria is an inherited metabolic defect The atrophy of the testis is the result of fibro-
in the renal tubular reabsorption of cystine, sis, which begins to appear in childhood and
ornithine, lysine and arginine. Cystine precipi- progresses until all the seminiferous tubules are
tates in an alkaline urine to form cystine stones. replaced by fibrous tissue. Gynaecomastia,
Triple phosphate stones are associated with mental retardation and eunuchoidism (see
infection and may develop into a very large EUNUCH; loss of male secondary sexual charac-
branching calculi (staghorn calculi). Stones teristics small penis, loss of body hair and a
present as renal or ureteric pain, or as an infec- high-pitched voice) may be present. Most
 Koilonychia 395

patients with Klinefelters syndrome have 47 slip beyond the edges of the bones, or it may
chromosomes instead of the normal 46. The become folded on itself. In either case, it tends
extra chromosome is an X chromosome, so that to cause locking of the joint when sudden
the sex chromosome constitution is XXY movements are made. This causes temporary
instead of XY. Klinefelters syndrome is one of inability to use the joint until the cartilage is
the most common chromosome abnormalities replaced by forcible straightening, and the
and occurs in 1 in 300 of the male population. accident is apt to be followed by an attack of
Patients with this syndrome show that the Y synovitis, which may last some weeks, causing
chromosome is strongly sex-determining: thus, lameness with pain and tenderness especially
a patient who has an XXY chromosome consti- felt at a point on the inner side of the knee.
tution may have the appearance of a normal This condition can be relieved by an operation
male, with infertility the only incapacity, while sometimes by keyhole surgery (see MINIMALLY
the loss of a Y chromosome leads to the devel- INVASIVE SURGERY (MIS)) to remove the loose
opment of a bodily form which is essentially portion of the cartilage. Patients whose knees
feminine (see TURNERS SYNDROME). are severely affected by osteoarthritis or
rheumatoid arthritis which cause pain and
Klumpkes Paralysis stiffness can now have the joint replaced with
Injury as a result of the stretching of a babys an artificial one. (See also ARTHROPLASTY;
brachial plexus during its birth may cause par- JOINTS, DISEASES OF.)
tial paralysis of the arm with atrophy of the
muscles of the forearm and hand. Knee Jerk
See REFLEX ACTION.
Knee
The joint formed by the FEMUR, TIBIA and Knee-Joint Replacement K
patella (knee-cap). It belongs to the class of A surgical operation to replace a diseased usu-
hinge-joints, although movements are much ally osteoarthritic KNEE with an artificial
more complex than the simple motion of a (metal or plastic) implant which covers the
hinge, the condyles of the femur partly rolling, worn cartilage. As much of the original joint as
partly sliding over the flat surfaces on the possible is retained. The operations, like hip
upper end of the tibia, and the acts of straight- replacements, are usually done on older people
ening and of bending the limb being finished (there is some restriction of movement) and
and begun, respectively, by a certain amount about 90 per cent are successful.
of rotation. The cavity of the joint is very Knock-Knee
intricate: it consists really of three joints fused Knock-knee, or genu valgum, is a deformity of
into one, but separated in part by ligaments the lower limbs in such a direction that when
and folds of the synovial membrane. The the limbs are straightened the legs diverge from
ligaments which bind the bones together are one another. As a result, in walking the knees
extremely strong, and include the popliteal knock against each other. The amount of
and the collateral ligaments, a very strong knock-knee is measured by the distance
patellar ligament uniting the patella to the between the medial malleoli of the ankles, with
front of the tibia, two CRUCIATE LIGAMENTS in the inner surfaces of the knee touching and the
the interior of the joint, and two fibro- knee-caps facing forwards. The condition is so
cartilages which are interposed between the common in children between the ages of 26
surfaces of tibia and femur at their edge. All years that it may almost be regarded as a normal
these structures give to the knee-joint great phase in childhood. When marked, or persist-
strength, so that it is seldom dislocated. The ing into later childhood, it can be corrected by
cruciate ligaments, although strong, sometimes surgery (osteotomy).
rupture or stretch under severe physical stress
such as contact sports or athletics. Surgical Kochs Bacillus
repair may be required, followed by prolonged The original name for Mycobacterium tubercu-
physiotherapy. losis, which causes TUBERCULOSIS. It stems from
A troublesome condition often found in the the name of the German doctor who first iden-
knee and common among athletes, footballers tified the bacillus.
and other energetic sportspeople consists of
the loosening of one of the fibro-cartilages lying Koilonychia
at the head of the tibia, especially of that on the The term applied to nails that are hollow and
inner side of the joint. The cartilage may either depressed like a spoon, a condition sometimes
be loosened from its attachment and tend to associated with chronic iron deficiency.
 396 Kopliks Spots

Kopliks Spots dren, and it was they who practised this rite.
Bluish-white spots appearing on the mucous Since the rite was given up, the disease has
membrane of the mouth in cases of MEASLES largely disappeared.
about the third day, and forming the first part
of the rash in this disease. Kveim Test
The characteristic histological test used for the
Korsakoffs Syndrome diagnosis of SARCOIDOSIS. The test involves an
A form of mental disturbance occurring in intradermal injection of sarcoid SPLEEN tissue.
chronic alcoholism and other toxic states, such If positive, non-caseating granulomata (see
as URAEMIA, lead poisoning and cerebral SYPH- GRANULOMA) are seen at the injection site in 4
ILIS. Its special features are talkativeness with 6 weeks. A positive test is highly specific for
delusions in regard to time and place the sarcoid, but if negative, this would not be
patient, although clear in other matters, excluded.
imagining that he or she has recently made
journeys. Kwashiorkor
One of the most important causes of ill health
Krebs Cycle and death among children in the tropics. It is
A series of key cellular chemical reactions start- predominantly a deficiency disease due to a diet
ing and ending with oxaloacetic acid. Also short of protein; there is also some evidence of
called the citric acid or tricarboxylic acid cycle, a lack of the so-called essential fatty acids. It
it produces energy in the form of ADENOSINE affects typically the small child weaned from
TRIPHOSPHATE (ATP) and is the last stage in the the breast and not yet able to cope with an
biological oxidation of fats, proteins, and car- adult diet, or for whom an adequate amount of
K bohydrates. Named after Sir Hans Krebs, a first-class protein is not available, and it is
German biochemist working in England in mainly found in the less well-developed
1900, who won the Nobel Prize for his countries.
discovery. The onset of the disease is characterised by
loss of appetite, often with diarrhoea and loss of
Kuntscher Nail weight. The child is flabby, the skin is dry, and
A surgical nail inserted into the medulla of a the hair is depigmented, dry, sparse and brittle.
fractured bone to fixate it. First introduced by a At a later stage OEDEMA develops and the liver
20th-century German surgeon. is often enlarged. In the early stages the condi-
tion responds rapidly to a diet containing
Kupffer Cells adequate first-class protein, but in the later
Star-shaped cells present in the blood-sinuses of stages this must be supplemented by careful
the LIVER. They form part of the RETICULO- nursing, especially as the child is very prone to
ENDOTHELIAL SYSTEM and are to a large extent infection.
responsible for the breakdown of HAEMO-
GLOBIN into the BILE pigments. Kyphoscoliosis
A combination of SCOLIOSIS and KYPHOSIS in
Kuru which the spine (see SPINAL COLUMN) is
A slowly progressive, fatal disease due to spongi- abnormally curved sideways and forwards. The
form degeneration in the central nervous sys- condition may be the result of several diseases
tem, particularly the cerebellum (see BRAIN). It affecting the spinal muscles and vertebrae, or it
is confined to the Fore people in the Eastern may happen during development for no obvi-
Highlands of New Guinea, and causes increas- ous reason. Although braces may reduce the
ingly severe muscular trembling. Kuru is deformity, an operation may be necessary to
believed to be due to an infection with a PRION, correct it.
similar to that causing CREUTZFELDT-JAKOB
DISEASE (CJD), acquired from the cannibalistic Kyphosis
rite of eating the organs, particularly the brains, The term applied to curvature of the spine in
of deceased relatives (out of respect). This ori- which the concavity of the curve is directed
gin of the disease was suggested by the fact that forwards. (See SPINE AND SPINAL CORD, DIS-
originally it was a disease of women and chil- EASES AND INJURIES OF.)
 Lacrimal

L See EYE Lacrimal apparatus.

Lacrimal Bones
The smallest bones of the face, one forming
part of the bony structure of each orbit contain-
ing an EYE.
Labetalol
Labetalol is an alpha- and beta-adrenoceptor Lacrimal Nerve
blocker (see ADRENERGIC RECEPTORS) used to A branch of the ophthalmic nerve supplying the
treat HYPERTENSION. Beta blockers block the lacrimal gland and conjunctiva of the EYE.
beta-adrenoceptors in the heart, peripheral
blood vessels and bronchi. Many drugs belong- Lacrimation
ing to this group are now available, and all are Crying, or the secretion of an excess quantity of
equally effective but with differences that may tears.
make them suitable for a particular patient.
Labetalol has the added property of dilating Lactase
arterioles (small arteries), thus lowering resist- An ENZYME produced by glands in the small
ance in the small peripheral blood vessels and INTESTINE which changes lactose (milk sugar)
helping to reduce blood pressure. into glucose and galactose during the process of
digestion.
Labia
Lips. The labia majora and labia minora are the Lactation
outer and inner lip-like folds of skin surround- The period during which an infant is suckled
ing the entrance to the VAGINA. on the mothers breast. (See also BREAST FEED-
ING; INFANT FEEDING.)
Labium
Labium is the Latin word for a lip or lip-shaped Lacteal
organ. A lymphatic vessel that transmits CHYLE from
the INTESTINE. (See also LYMPH.)
Labour
See PREGNANCY AND LABOUR. Lactic Acid
A colourless, syrupy, sour liquid, which is pro-
Labyrinth duced by the action of a bacterium upon lac-
A convoluted system of structures forming tose, the sugar found in milk. The growth of
the inner EAR and involved in hearing and this organism and consequent formation of lac-
balance. tic acid cause the souring of milk, and the same
change takes place to a limited extent when
Labyrinthitis food is long retained in the stomach.
Inflammation of the LABYRINTH of the EAR. Lactic acid (CH3.CHOH.COOH) is pro-
Usually caused by bacterial or viral infection, duced in the body during muscular activity, the
the former often the result of inadequately lactic acid being derived from the breakdown of
treated otitis media (see EAR, DISEASES OF Dis- GLYCOGEN. Muscle fatigue is associated with an
eases of the middle ear), or MEASLES. Symptoms accumulation of lactic acid in the muscle.
are VERTIGO, nausea, vomiting, nystagmus (see Recovery follows when enough oxygen gets to
EYE, DISORDERS OF), TINNITUS and loss of hear- the muscle, part of the lactic acid being oxidised
ing. Bacterial infection needs treatment with and most of it then being built up once more
ANTIBIOTICS; viral infection is usually self- into glycogen.
limiting. ANTIHISTAMINE DRUGS will help
reduce the vertigo. Rarely, surgery may be Lactobacillus
required to drain the infection in bacteria-based A gram-positive (see GRAMS STAIN), rod-shaped,
labyrinthitis. non-motile bacterium (see BACTERIA). It pro-
duces LACTIC ACID by fermenting CARBO-
Laceration HYDRATE. Lactobacilli are found in fermenting
A wound to the skin or surface of an organ animal and plant products, especially dairy
which results in a cut with irregular edges (cf. products; they also occur in the GASTROINTEST-
an incision produced with a knife, which has INAL TRACT and the VAGINA. L. acidophilus
smooth, regular edges). occurs in milk and is a contributory cause to the
 398 Lactose

development of dental caries (see TEETH, DIS- Lanolin

ORDERS OF). Derived from wool fat, it is an ingredient of
many ointments and creams but may cause
Lactose allergic contact DERMATITIS.
The official name for sugar of milk.
Lansoprazole
Lactose Intolerance One of the PROTON-PUMP INHIBITORS, it
is due to lack in the INTESTINE of the ENZYME blocks the proton pump ENZYME system of
known as LACTASE which is responsible for the the STOMACHs acid-producing PARIETAL cells.
digestion of lactose, the sugar in milk. The It is used in short-term treatment of PEPTIC
result is that drinking milk or eating milk- ULCER and in combination with antibacterial
containing products is followed by nausea, a drugs to eliminate infection with the bacteria
sensation of bloating, or distension, in the gut, HELICOBACTER PYLORI.
abdominal pain and diarrhoea. (Similar dis-
turbances after taking milk may also occur in Lanugo
those who do not lack lactase but have an Soft fine hair covering the FETUS. It disappears
allergy to milk protein). Treatment is by means by the ninth month of gestation and is therefore
of a low-lactose diet avoiding fresh or powdered only seen on premature babies.
milk and milk puddings. Many can tolerate
fermented milk products, as well as the small Laparoscope
amounts of milk used in baking and added to An instrument consisting, essentially, of a rigid
margarine and sausages. However, infamts may or flexible cylinder, an eyepiece and a light
have to be fed exclusively on a lactose-free for- source, which is inserted through a small inci-
mula as even breast milk may produce sion into the abdominal cavity (which has
symptoms. already been distended with carbon dioxode
L gas). The laparoscope allows the contents of the
Lactulose abdominal cavity to be examined without per-
An osmotic laxative (see OSMOSIS; LAXATIVES), forming a LAPAROTOMY. Some operations may
lactulose is a semisynthetic disaccharide a type be performed using the laparoscope to guide
of carbohydrate which is not absorbed from the manipulation of instruments inserted
the GASTROINTESTINAL TRACT. It reduces the through another small incision for example,
acidity of FAECES. STERILISATION; CHOLECYSTECTOMY. (See also
ENDOSCOPE; MINIMALLY INVASIVE SURGERY
(MIS).)
Lacuna
A small pit or depression.
Laparoscopy
Also called peritoneoscopy, this is a technique
Lamblia using an instrument called an ENDOSCOPE for
See GIARDIASIS.
viewing the contents of the ABDOMEN. The
instrument is inserted via an incision just below
Lamella the UMBILICUS and air is then pumped into the
A small disc of glycerin jelly, 3 mm (1/8 inch) peritoneal (abdominal) cavity. Visual inspection
in diameter, containing an active drug for may help in the diagnosis of cancer, APPENDI-
application to the eye. It is applied by insertion CITIS, SALPINGITIS, and abnormalities of the
behind the lower lid. LIVER, GALL-BLADDER, OVARIES or GASTRO-
INTESTINAL TRACT. A BIOPSY can be taken of
Laminectomy tissue suspected of being abnormal, and oper-
An operation in which the arches of one or ations such as removal of the gall-bladder or
more vertebrae in the SPINAL COLUMN are appendix may be carried out. (See also MINIM-
removed so as to expose a portion of the SPINAL ALLY INVASIVE SURGERY (MIS).)
CORD for removal of a tumour, relief of pressure
due to a fracture (see under BONE, DISORDERS Laparotomy
OF), or disc protrusion. A general term applied to any operation in
which the abdominal cavity is opened (see
Lamotrigine ABDOMEN). A laparotomy may be exploratory
An antiepileptic drug for the treatment of to establish a diagnosis, or carried out as a pre-
patients with EPILEPSY, whose condition is liminary to major surgery. Viewing of the peri-
characterised by partial seizures. toneal cavity (see PERITONEUM) through an
 Larynx, Disorders of 399

ENDOSCOPE is called a LAPAROSCOPY or Larynx, Disorders of

peritoneoscopy.
Obstruction of the larynx is potentially
Larva dangerous in adults but can sometimes be life-
The pre-adult stage in insects and nematodes threatening in infants and children. Stridor
occurring between the egg and the sexually noisy, difficult breathing is a symptom of
mature adult. obstruction. There are several causes, including
congenital abnormalities of the larynx. Others
Larva Migrans are inflammatory conditions such as acute
A self-limiting, intensely itching skin eruption laryngitis (see below), acute EPIGLOTTITIS and
caused by nematode (roundworm) larvae, usu- laryngo-tracheo-bronchitis (croup see below);
ally of the dog and cat hookworm (see ANCY- neurological abnormalities; trauma; and inhal-
LOSTOMIASIS). The migrating larvae leave red, ation of foreign bodies.
raised, irregular tracks in the skin, often on
the foot and less frequently elsewhere. The Laryngitis Inflammation of the mucous
disease is usually acquired by people who take membrane of the larynx and vocal chords may
their holidays on tropical beaches. It can be be acute or chronic. The cause is usually an
cured by a three-day course of oral infection, most commonly viral, although it
ALBENDAZOLE. may be the result of secondary bacterial infec-
tion, voice abuse or irritation by gases or
Laryngeal Reflex chemicals.
A protective cough occurring as a result of irri- ACUTE LARYNGITIS may accompany any form
tation of the LARYNX for example, a small of upper-respiratory-tract infection. The main
particle of food may be accidentally inhaled symptom is hoarseness and often pain in the
into the larynx, which reacts with an expulsive throat. The voice becomes husky or it may be
cough to prevent the food from entering the lost. Cough, breathing difficulties and some- L
lungs. times stridor may occur. Acute airway obstruc-
tion is unusual following laryngitis but may
occasionally occur in infants (see laryngo-
Laryngectomy tracheo-bronchitis, below).
Operation for removal of the LARYNX.
Treatment Vapour inhalations may be sooth-
Laryngitis ing and reduce swelling. Usually all that is
See LARYNX, DISORDERS OF.
needed is rest and analgesics such as paraceta-
mol. Rarely, airway intervention either
Laryngology ENDOTRACHEAL INTUBATION or TRACHE-
See OTOLARYNGOLOGY. OSTOMY may be necessary if severe airway
obstruction develops (see APPENDIX 1: BASIC
Laryngoscope FIRST AID). Affected patients should rest their
Examination of the LARYNX may be performed voice and avoid smoking.
indirectly with use of a laryngeal mirror, or dir-
ectly by use of a laryngoscope a type of Chronic laryngitis can result from repeated
endoscope. The direct examination is usually attacks of acute laryngitis; excessive use of the
performed under general anaesthetic. voice loud and prolonged, singing or shout-
ing; tumours, which may be benign or
Laryngo-Tracheo-Bronchitis malignant; or secondary to diseases such as
Also known as croup see under LARYNX, DIS- TUBERCULOSIS and SYPHILIS.
ORDERS OF. Benign tumours or small nodules, such as
singers nodules, may be surgically removed by
Larynx direct laryngoscopy under general anaesthetic;
The organ of voice which also forms one of the while cancer of the larynx may be treated either
higher parts of the AIR PASSAGES. It is placed by RADIOTHERAPY or by SURGERY, depending
high up in the front of the neck and there forms on the extent of the disease. Hoarseness may be
a considerable prominence on the surface the only symptom of vocal-chord disturbance
(Adams apple). The vocal cords vibrating in or of laryngeal cancer: any case which has lasted
different notes, according to their tenseness and for six weeks should be referred for a specialist
the like, produce the sounds of VOICE AND opinion.
SPEECH. Laryngectomy clubs are being established
 400 Larynx, Disorders of

Diagram of the opening of the larynx to show the

action of the muscles. The cords are now held
Diagram of the opening of the larynx to show the together by the action of 3, 4 and 7.
action of the muscles. A horizontal section has
been made at the level of the true vocal cords. The
two cords are widely separated by the action of 4.

Anatomy of the larynx.

 Lasik 401

produced. The wavelength determines the

degree of energy absorption by different tissues,
and because of this, different lasers are needed
for different tasks. The argon laser produces
light in the visible green wavelength which is
selectively absorbed by HAEMOGLOBIN. It heats
and coagulates (see COAGULATION) tissues so
can be used to seal bleeding blood vessels and to
selectively destroy pigmented lesions. The
carbon-dioxide laser is the standard laser for
cutting tissue: the infra-red beam it produces is
strongly absorbed by water and so vaporises
cells. Thus, by moving a finely focused beam
across the tissue, it is possible to make an
incision.
The two main uses of laser in surgery are the
endoscopic (see ENDOSCOPE) photocoagulation
of bleeding vessels, and the incision of tissue.
A laryngoscopic view of the interior of the larynx.
Lasers have important applications in OPH-
THALMOLOGY in the treatment of such dis-
throughout the country to support patients fol- orders as detachment of the retina and the
lowing laryngectomy. Speech therapists provide diabetic complications of proliferative retin-
speech rehabilitation. opathy and of the cornea (see EYE, DISORDERS
OF). The destruction of abnormal cells a sign
Laryngo-tracheo-bronchitis of pre-malignancy in the CERVIX UTERI is
Also known as croup. An acute infection of the done using lasers. The beams may also be used
respiratory tract in infants and young children, L
to remove scar tissue from the FALLOPIAN
usually caused by parainfluenza virus. The TUBES resulting from infection, thus unblock-
onset is variable but the croupy cough and ing the tubes and improving the chances of
stridulous breathing usually occur a few days CONCEPTION. Lasers also have several import-
after the onset of a viral upper-respiratory-tract ant applications in DERMATOLOGY. They are
infection. A harsh barking cough is typical of used in the treatment of pigmented lesions
the condition. The majority of affected children such as LENTIGO, in the obliteration of port-
can be treated with HUMIDIFICATION and a sin- wine stains, in the removal of small, benign
gle dose of inhaled corticosteroid (budesonide tumours such as verrucas, and finally in the
see CORTICOSTEROIDS) or a single days treat- removal of tattoos.
ment with oral prednisolone. Severe croup can Low-intensity laser beams promote tissue
cause serious breathing problems when the healing and reduce inflammation, pain and
child should be referred for urgent specialist swelling. Their effect is achieved by stimulating
assessment, and hospitalisation is preferable in blood and lymph flow and by cutting the pro-
all cases. Rarely, some form of intervention is duction of PROSTAGLANDINS, which provoke
necessary and this will either be in the form of inflammation and pain. The beams are used to
endotracheal intubation or of a tracheostomy. treat ligament sprains, muscle tears and
inflamed joints and tendons.
Laser The three great advantages of lasers are their
Laser stands for Light Amplification by Stimu- potency, their speed of action, and the ability to
lated Emission of Radiation. The light pro- focus on an extremely small area. For these
duced by a laser is of a single wavelength and all reasons they are widely used, and have allowed
the waves are in phase with each other, allowing great advances to be made in microsurgery, and
a very high level of energy to be projected as a particularly in FIBREOPTIC ENDOSCOPY.
parallel beam or focused on to a small spot.
Various gases, liquids and solids will emit Lasik
light when they are suitably stimulated. A Acronym for laser in-situ keratomileusis, which
gassed laser is pumped by the ionising effect of a is a variety of surgery of the EYE used to correct
high-voltage current. This is the same process as severe myopia (short-sightedness see REFRAC-
that used in a fluorescent tube. Each type of TION; EYE, DISORDERS OF). A thin flap of the
laser has a different effect on biological tissues cornea is lifted, the area underneath reshaped
and this is related to the wavelength of the light using an EXCIMER LASER, and the flap is then
 402 Lassa Fever

returned to its place, the altered contour of the People should be aware that normal bowel
cornea improving the patients sight. habits vary greatly, from twice a day to once
every two or even three days. Any change from
Lassa Fever normal frequency to irregular or infrequent
First reported in Lassa, in Nigeria, and caused defaecation may signal constipation. Further-
by an arenavirus transmitted by rodents or dir- more, before laxatives are prescribed, it is essen-
ect from an infected person. The incubation tial to ensure that the constipation is not the
period is 321 days. It is characterised by head- result of an underlying condition producing
ache, lethargy and severe muscular pains, and secondary constipation. Individuals should
there is often a rash due to bleeding into the not use laxatives too often or indiscriminately;
skin and mucous membranes. Sore throat is persistent constipation is a reason to seek med-
often present. It may carry a high mortality rate, ical advice.
particularly in pregnant women. There is no
specific treatment, and all that can be done is Bulk laxatives include bran and most high-
supportive nursing. fibre foods, such as fruit, vegetables and
wholemeal foods. These leave a large indigest-
Lassars Paste ible residue that holds water in the gut and pro-
Officially known as Zinc and Salicylic Acid duces a large soft stool. Isphaghula husk,
Paste, BP, this preparation is an old remedy for methyl cellulose and stercula are helpful when
eczema (see DERMATITIS). bran is ineffective. Inorganic salts such as mag-
nesium sulphate (Epsom Salts) have a similar
Lassitude effect.
See LETHARGY.
Stimulant laxatives for example, bisacodyl,
Latanoprost senna and docusate sodium stimulate PERI-
An analogue of prostaglandin (see PROSTA- STALSIS,although the action may be accom-
L GLANDINS), used to treat open-angled GLAU-
panied by colicky pains.
COMA and raised intra-ocular pressure in the
EYE. Delivered as an eye drop, the drug is used
Faecal softeners (emollients) There are
in patients who cannot tolerate, or who fail to two groups: surface active agents such as dioctyl
respond to, other treatments. sodium and sulphosuccinate which retain water
in the stools and are often combined with a
Lateral stimulant purgative; and liquid paraffin which
Referring to the sides of an organ or of the
is chemically inert and is said to act by
body, or that part furthest from the mid line or
lubrication.
median plane.

Latissimus Dorsi Osmotic laxatives These substances act by

A large, flat, triangular muscle in the back. holding fluid in the bowel by OSMOSIS, or by
altering the manner in which water is distrib-
Laughing Gas uted in the FAECES. Magnesium salts are used to
A popular name for NITROUS OXIDE GAS. produce rapid bowel evacuation, although one
of them, magnesium hydroxide, should be used
Lavage only occasionally. Phosphate or sodium citrate
The name applied to the washing-out of the enemas (see ENEMA) can be used for constipa-
stomach, for example to deal with potentially tion, while the former is used to ensure bowel
harmful drug ingestion. (See GASTRIC LAVAGE.) evacuation before abdominal radiological
procedures, endoscopy and surgery.
Laxatives
Drugs or other substances used to treat CON- Lead Poisoning
STIPATION. Also called aperients or purgatives, Lead and lead compounds are used in a variety
laxatives are classified according to their mode of products including petrol additives (in the
of action. The four main groups are bulk, UK, lead-free petrol is now mandatory), piping
stimulant, faecal softeners and osmotics. In (lead water pipes were once a common source
addition, bowel-cleansing solutions are used of poisoning), weights, professional paints,
before surgery, ENDOSCOPY, or radiological dyes, ceramics, ammunition, homeopathic
examination of the COLON, to ensure that the remedies, and ethnic cosmetic preparations.
bowel is clear of solid matter. However, these Lead compounds are toxic by ingestion, by
are not procedures for treating constipation. inhalation and, rarely, by skin exposures. Metal-
 Learning Disability 403

lic lead, if ingested, is absorbed if it remains in need more intensive inpatient treatment, and a
the gut. The absorption is greater in children, very small minority with disturbed behaviour
who may ingest lead from the paint on old cots need secure (i.e. locked) settings.
although lead-containing paints are no longer In the United Kingdom, the 1993 Education
used for items that children may be in contact Act refers to learning difficulties: generalised
with. (severe or moderate), or specific (e.g. DYSLEXIA,
Acute poisonings are rare. Clinical features dyspraxia [or APRAXIA], language disorder). The
include metallic taste, abdominal pain, vomit- 1991 Social Security (Disability Living Allow-
ing, diarrhoea, ANOREXIA, fatigue, muscle ance) Regulations use the term severely men-
weakness and SHOCK. Neurological effects may tally impaired if a person suffers from a state of
include headache, drowsiness, CONVULSIONS arrested development or incomplete physical
and COMA. Inhalation results in severe development of the brain which results in
respiratory-tract irritation and systemic symp- severe impairment of intelligence and social
toms as above. functioning. This is distinct from the con-
Chronic poisonings cause gastrointestinal sequences of DEMENTIA. Though mental
disturbances and constipation. Other effects are handicap is widely used, learning disability is
ANAEMIA, weakness, pallor, anorexia, preferred by the Department of Health.
insomnia, renal HYPERTENSION and mental There is a distinction between impairment (a
fatigue. There may be a bluish lead line on the biological deficit), disability (the functional
gums, although this is rarely seen. Neuro- consequence) and handicap (the social
muscular dysfunction may result in motor consequence).
weakness and paralysis of the extensor muscles People with profound learning disability are
of the wrist and ankles. ENCEPHALOPATHY and usually unable to communicate adequately and
nephropathy are severe effects. Chronic low- may be seriously movement-impaired. They are
level exposures in children are linked with totally dependent on others for care and mobil-
reduced intelligence and behavioural and learn- ity. Those with moderate disability may achieve L
ing disorders. basic functional literacy (recognition of name,
common signs) and numeracy (some under-
Treatment Management of patients who standing of money) but most have a life-long
have been poisoned is supportive, with removal dependency for aspects of self-care (some fas-
from source, gastric decontamination if tenings for clothes, preparation of meals, men-
required, and X-RAYS to monitor the passage of strual hygiene, shaving) and need supervision
metallic lead through the gut if ingested. It is for outdoor mobility.
essential to ensure adequate hydration and Children with moderate learning disability
renal function. Concentrations of lead in the develop at between half and three-quarters of
blood should be monitored; where these are the normal rate, and reach the standard of an
found to be toxic, chelation therapy should average child of 811 years. They become
be started. Several CHELATING AGENTS are independent for self-care and public transport
now available, such as DMSA (Meso-2,3- unless they have associated disabilities. Most are
dimercaptosuccinic acid), sodium calcium ede- capable of supervised or sheltered employment.
tate (see EDTA) and PENICILLAMINE. (See also Living independently and raising a family may
POISONS.) be possible.

Learning Disability Occurrence Profound learning disability

Learning disability, previously called mental affects about 1 in 1,000; severe learning dis-
handicap, is a problem of markedly low intel- ability 3 in 1,000; and moderate learning dis-
lectual functioning. In general, people with ability requiring special service, 1 per cent.
learning disability want to be seen as them- With improved health care, survival of people
selves, to learn new skills, to choose where to with profound or severe learning disability is
live, to have good health care, to have girl- increasing.
friends or boyfriends, to make decisions about
their lives, and to have enough money to live Causation Many children with profound or
on. They may live at home with their families, severe learning disability have a diagnosable
or in small residential units with access to work biological brain disorder. Forty per cent have a
and leisure and to other people in ordinary chromosome disorder see CHROMOSOMES
communities. Some people with learning dis- (three quarters of whom have DOWNS (DOWN)
abilities, however, also have a MENTAL ILLNESS. SYNDROME); a further 15 per cent have
Most can be treated as outpatients, but a few other genetic causes, brain malformations or
 404 Lebers Disease

recognisable syndromes. About 10 per cent suf- or boarding school. Other children can be pro-
fered brain damage during pregnancy (e.g. from vided for in mainstream schools with extra
CYTOMEGALOVIRUS (CMV) infection) or from classroom support. The 1993 Education Act
lack of oxygen during labour or delivery. A simi- lays down stages of assessment and support up
lar proportion suffer postnatal brain damage to a written statement of special educational
from head injury accidental or otherwise needs with annual reviews.
near-miss cot death or drowning, cardiac arrest, Pupils with learning disability are entitled to
brain infection (ENCEPHALITIS or MENINGITIS), remain at school until the age of 19, and most
or in association with severe seizure disorders. with severe or profound learning disability do
Explanations for moderate learning disability so. Usually those with moderate learning dis-
include Fragile X or other chromosome ability move to further education after the age
abnormalities in a tenth, neurofibromatosis (see of 16.
VON RECKLINGHAUSENS DISEASE), fetal alcohol Advice is available from the Mental Health
syndrome and other causes of intra-uterine Foundation, the British Institute of Learning
growth retardation. Genetic counselling should Disabilities, MENCAP (Royal Society for Men-
be considered for children with learning dis- tally Handicapped Children and Adults), and
ability. Prenatal diagnosis is sometimes possible. ENABLE (Scottish Society for the Mentally
In many children, especially those with mild or Handicapped).
moderate disability, no known cause may be
found. Lebers Disease
A hereditary disease in which blindness comes
Medical complications EPILEPSY affects 1 on at about the age of 20.
in 20 with moderate, 1 in 3 with severe and 2 in
3 with profound learning disability, although Lecithin
only 1 in 50 with Downs syndrome is affected. A very complex fat found in various tissues of
L One in 5 with severe or profound learning dis- the body, but particularly in the brain and
ability has CEREBRAL PALSY. nerves, of which it forms a large part. It is also
found in large quantities in the yolk of an egg.
Psychological and psychiatric
needs Over half of those with profound or Leeches
severe and many with moderate learning Animals provided with suckers surrounding the
disability show psychiatric or behavioural prob- mouth, and living a semi-parasitic life, their
lems, especially in early years or adolescence. food being mainly derived from the blood of
Symptoms may be atypical and hard to assess. other animals. They abstract blood by means of
Psychiatric disorders include autistic behaviour the sucker, which has several large, sharp teeth.
(see AUTISM) and SCHIZOPHRENIA. Emotional Land leeches live in tropical forests and can
problems include anxiety, dependence and attach themselves to a persons ankles and lower
depression. Behavioural problems include tan- legs. Aquatic leeches are found in warm water
trums, hyperactivity, self-injury, passivity, mas- and may attach themselves to swimmers. Their
turbation in public, and resistance to being bites are painless, their saliva reducing the clot-
shaved or helped with menstrual hygiene. ting properties of blood with hirudin; the result
There is greater vulnerability to abuse with its is that the wound continues to bleed after the
behavioural consequences. leech has detached itself or been gently removed
(lighted match, alcohol, salt and vinegar are
Respite and care needs Respite care is effective removal agents). The medicinal leech,
arranged with link families for children or Hirudo medicinalis, was formerly employed for
staffed family homes for adults where possible. the abstraction of small quantities of blood in
Responsibility for care lies with social services inflammatory and other conditions. Nowadays
departments which can advise also about it is occasionally used to drain haematomas and
benefits. to manage healing in certain types of plastic
surgery.
Education Special educational needs should
be met in the least restrictive environment Left to Right Shunt
available to allow access to the national curric- A term used when a hole in the septum
ulum with appropriate modification and sup- (internal wall) of the HEART allows blood to
port. For older children with learning disability, flow from the systemic circulation properly
and for young children with severe or profound confined to the left side of the heart to the pul-
learning disability, this may be in a special day monary circulation, confined to the right. The
 Leproma 405

shunt is usually detected by hearing a murmur, Untreated, the infection is fatal within two
and the diagnosis confirmed by ECHOCARDI- years, in approximately 70 per cent of patients.
OGRAPHY (see also SEPTAL DEFECT). Treatment traditionally involved sodium sti-
bogluconate, but other chemotherapeutic
Legionnaires Disease agents (including allupurinol, ketoconazole,
A form of PNEUMONIA due to a bacterium and immunotherapy) are now in use, the most
known as Legionella pneumophila, so-called recently used being liposomal amphotericin B.
because the first identified outbreak was in a Although immunointact persons usually
group of US ex-servicemen (members of the respond satisfactorily, they are likely to relapse
American Legion). Inhalation of water aerosols if they have HIV infection (see AIDS/HIV).
seems the most likely way that people acquire
the disease, for example from air-conditioning Cutaneous leishmaniasis This form is
outlets. Some rubber outlets in showers and caused by infection with L. tropica, L. major,
taps are able to support the growth of legionnel- L. aethiopica, and other species. The disease is
lae so that high concentrations of the organism widely distributed in the Mediterranean
are released when the tap is first used in the region, Middle East, Asia, Africa, Central and
morning. In the presence of the disease, the South America, and the former Soviet Union.
treatment of infected water systems is essential It is characterised by localised cutaneous ulcers
by cleaning, chlorination, heating or a combin- usually situated on exposed areas of the
ation of all three. body. Diagnosis is by demonstration of the
The pneumonia caused by legionnellae has causative organism in a skin biopsy-specimen;
no distinctive clinical or radiological features, so the leishmanin skin test is of value. Most
that the diagnosis is based on an antibody test patients respond to sodium stibogluconate (see
performed on a blood sample. There is no evi- above); local heat therapy is also used. Paro-
dence that the disease is transmitted directly momycin cream has been successfully applied
from person to person. The incubation period locally. L
is 210 days; the disease starts with aches and
pains followed rapidly by a rise in temperature, Mucocutaneous leishmaniasis This
shivering attacks, cough and shortness of form is caused by L. braziliensis and rarely L.
breath. The X-ray tends to show patchy areas of mexicana. It is present in Central and South
consolidation in the lungs. Erythromycin and America, particularly the Amazon basin, and
rifampicin are the most useful antibiotics, characterised by highly destructive, ulcerative,
although rifampicin should never be given granulomatous lesions of the skin and mucous
alone because of the rapid development of drug membranes, especially involving the mucocu-
resistance. taneous junctions of the mouth, nasopharynx,
genitalia, and rectum. Infection is usually via a
Leiomyoma superficial skin lesion at the site of a sandfly
A benign tumour made up of unstriped or bite. However, spread is by haematogenous
involuntary muscle fibres. routes (usually after several years) to a mucocu-
taneous location. Diagnosis and treatment are
Leishmaniasis the same as for cutaneous leishmaniasis.
A group of infections caused by parasites
transmitted to humans by sandflies. Lens of the Eye
See EYE.
Visceral leishmaniasis (kala-azar) A
systemic infection caused by Leishmania dono- Lentigo
vani which occurs in tropical and subtropical Lentigines (freckles) are brown MACULES vary-
Africa, Asia, the Mediterranean littoral (and ing in diameter from 110 mm or more. Simple
some islands), and in tropical South America. lentigines arise in childhood, not necessarily on
Onset is frequently insidious; incubation period exposed areas. They may also occur on the lips
is 26 months. Enlargement of spleen and liver and are harmless and usually very small. Solar
may be gross; fever, anaemia, and generalised or actinic lentigines are common on the face,
lymphadenopathy are usually present. Diag- neck and backs of the hands in older people and
nosis is usually made from a bone-marrow reflect the total cumulative lifetimes exposure
specimen, splenic-aspirate, or liver-biopsy to sunlight.
specimen; amastigotes (Leishman-Donovan
bodies) of L. donovani can be visualised. Several Leproma
serological tests are of value in diagnosis. A nodule in the skin occurring in LEPROSY.
 406 Leprosy

Leprosy ment of the disease. More recently, rifampicin

Also known as Hansens disease, this is a and clofazimine have been added as first-line
chronic bacterial infection caused by Mycobac- drugs for treatment. Second-line drugs include
terium leprae affecting the skin, mucous mem- minocycline, ofloxacin and clarithromycin; a
branes, and nerves. Infection is now almost number of regimens incorporating several of
confined to tropical and subtropical countries these compounds (multi-drug regimens
mostly in Africa and India. There are two dis- introduced in 1982) are now widely used. A
tinct (polarised) clinical forms: tuberculoid and three-drug regime is recommended for multi-
lepromatous. The former usually takes a benign bacillary leprosy and a two-drug one for parci-
course and frequently burns out, whereas the bacillary leprosy. Dapsone resistance is a major
latter is relentlessly progressive; between these problem worldwide, but occurs less commonly
two polar forms lies an intermediate/dimorph- when multi-drug regimens are used. Older
ous group. Susceptibility may be increased compounds ethionamide and prothionamide
by malnutrition. Nasal secretions (especially are no longer used because they are severely
in lepromatous disease) are teeming with M. toxic to the liver. Corticosteroids are sometimes
leprae and constitute the main source of infec- required in patients with reversal reaction.
tion; however, living in close proximity to an Supportive therapy includes physiotherapy;
infected individual seems necessary for some- both plastic and orthopaedic surgery may be
one to contract the disease. M. leprae can also necessary in advanced stages of the disease.
be transmitted in breast milk from an infected Improvement in socio-economic conditions,
mother. and widespread use of BCG vaccination are of
Only a small minority of those exposed to M. value as preventive strategies. Early diagnosis
leprae develop the disease. The incubation and prompt institution of chemotherapy
period is 35 years or longer. The major clinical should prevent long-term complications.
manifestations involve skin and nerves: the
L former range from depigmented, often anaes- Leptospira
thetic areas, to massive nodules; nerve involve- A group, or genus, of spiral micro-organisms,
ment ranges from localised nerve swelling(s) to normally found in rodents and other small
extensive areas of anaesthesia. Advanced nerve mammals in which they cause no harm. When
destruction gives rise to severe deformities: transmitted to humans by these animals, either
foot-drop, wrist-drop, claw-foot, extensive directly or indirectly as through cows, they give
ulceration of the extremities with loss of fingers rise to various forms of illness (see
and toes, and bone changes. Eye involvement LEPTOSPIROSIS).
can produce blindness. Laryngeal lesions pro-
duce hoarseness and more serious sequelae. Leptospirosis
The diagnosis is essentially a clinical one; how- The disease caused by infection with LEPT-
ever, skin-smears, histological features and the OSPIRA. The three most common members of
lepromin skin-test help to confirm the diag- this group in the United Kingdom are L. ictero-
nosis and enable the form of disease to be haemorrhagiae, L. cani-cola, and L. hebdomadis.
graded. It is an occupational hazard of farmers, sewage
Although the World Health Organisation and abattoir workers, fish cutters and veterinary
had originally hoped to eliminate leprosy surgeons, but the infection can also be acquired
worldwide by 2000, that has proved an from bathing in contaminated water. The dis-
unrealistic target. The reason is an absence of ease varies in intensity from a mild influenza-
basic information. Doctors are unable to diag- like illness to a fatal form of JAUNDICE due to
nose the disorder before a patient starts to show severe liver disease. The kidneys are often
symptoms; meanwhile he or she may have involved and there may be MENINGITIS. Penicil-
already passed on the infection. Doctors do not lin or tetracycline are the usual treatment, but
know exactly how transmission occurs or how it unless they are given early in the disease their
infects humans nor do they know at what effect is limited. The tetracycline antibiotic
point a carrier of the bacterium may infect doxycycline (see TETRACYCLINES) given once
others. The incidence of new infections is still weekly during periods of exposure prevents
more than 650,000 cases a year or about 4.5 infection.
cases per 10,000 people in those countries
worst affected by the disease. Spirochaetosis icterohaemorrhagica
Also known as Weils disease, this is the term
Treatment Introduction of the sulphone applied to infection with the Leptospira ictero-
compound, dapsone, revolutionised manage- haemorrhagiae which is transmitted to humans
 Leucocytes 407

by rats these animals excreting the organism hypothyroidism (see THYROID GLAND, DISEASES
in their urine, hence the liability of sewage OF). Some of these patients have a true depres-
workers to the disease. The condition is sive illness and their presentation and response
characterised by fever, jaundice, enlarged liver, to treatment is little different from that of suf-
nephritis, and bleeding from mucous ferers of any other depressive illness, URAEMIA,
membranes. alcoholism and DIABETES MELLITUS.

Lesbian Leucine
A female homosexual (see HOMOSEXUALITY); One of the essential, or indispensable, AMINO
lesbians form about 2 per cent of the female ACIDS. They are so-called because they cannot
population in the UK. Some engage in active be synthesised, or manufactured, in the body,
sexual behaviour with another woman, with and are therefore essential constituents of the
MASTURBATION, mutual stimulation of the diet.
CLITORIS and oral sex being the usual tech-
niques for achieving ORGASM. Leuco-
Or leuko- a prefix meaning white.
Lesion
Lesion meant originally an injury, but is now Leucocytes
applied generally to all disease changes in The scientific name for white blood cells.
organs and tissues. Leucocytes contain no HAEMOGLOBIN so are
colourless, and have a well-formed NUCLEUS.
Lethal Gene Healthy people have around 8,000 leucocytes
A gene that produces a GENOTYPE which causes per cubic millimetre of blood. There are three
the death of an organism before that organism main classes of white cells: granulocytes,
has reproduced or which prevents it from lymphocytes and monocytes.
reproducing. Lethal genes are usually RECES- L
SIVE, so the organism will die only if both its Granulocytes Also known as polymorpho-
parents carry the gene. Should only one parent nuclear leucocytes (polys), these normally
have the lethal gene, its consequences will be constitute 70 per cent of the white blood cells.
masked by the dominant ALLELE passed on by They are divided into three groups according to
the normal parent. the staining reactions of these granules: neutro-
phils, which stain with neutral dyes and consti-
Lethargy tute 6570 per cent of all the white blood cells;
Lethargy, or lassitude, means a loss of energy. It eosinophils, which stain with acid dyes (e.g.
is a common presenting complaint both to gen- eosin) and constitute 34 per cent of the total
eral practitioners and to hospital consultants. It white blood cells; and basophils, which stain
may have a physical cause or a psychological with basic dyes (e.g. methylene blue) and con-
cause; it may be the result of inadequate rest, stitute about 05 per cent of the total white
environmental noise, boredom, insomnia or blood cells.
recent illness. Certain medicinal drugs can
cause lethargy, the most common being beta Lymphocytes constitute 2530 per cent of
blockers (see BETA-ADRENOCEPTOR-BLOCKING the white blood cells. They have a clear, non-
DRUGS) and DIURETICS, and drugs of abuse granular cytoplasm and a relatively large
may also be a cause (see DEPENDENCE). The nucleus which is only slightly indented. They
common psychosocial problems producing are divided into two groups: small lymphocytes,
lethargy are DEPRESSION and anxiety. which are slightly larger than erythrocytes
If the patient with lethargy runs a fever, the (about 8 micrometres in diameter); and large
differential diagnosis is that of a PUO (pyrexia lymphocytes, which are about 12 micrometres
of unknown origin). Many patients with fatigue in diameter.
can establish the onset of the symptom to a
febrile illness even though they no longer run a Monocytes Motile phagocytic cells that cir-
fever. The lethargy that follows some viral infe- culate in the blood and migrate into the tissues,
cions, such as HEPATITIS A and glandular fever where they develop into various forms of
(see MONONUCLEOSIS) is well recognised; MACROPHAGE such as tissue macrophages and
MYALGIC ENCEPHALOMYELITIS (ME) or chronic KUPFFER CELLS.
fatigue syndrome is another disorder associated
with lethargy and tiredness. Organic causes of Site of origin The granulocytes are formed
lethargy include ANAEMIA, malnutrition and in the red BONE MARROW. The lymphocytes are
 408 Leucocytosis

formed predominantly in LYMPHOID TISSUE. discharges with an offensive smell and yellow or
There is some controversy as to the site of origin green colouring: these may be caused by
of monocytes: some say they arise from micro-organisms or by fungal infection such as
lymphocytes, whilst others contend that they Candida albicans. Another causative agent is
are derived from histiocytes i.e. the the protozoan parasite, Trichomonas vaginalis
RETICULO-ENDOTHELIAL SYSTEM. (see TRICHOMONIASIS). A pessary or tampon
that a woman has forgotten to remove will
Function The leucocytes constitute one of cause a substantial and offensive discharge.
the most important of the defence mechanisms Children rarely have vaginal discharge; if they
against infection. This applies particularly to do, it is usually due to an infection or foreign
the neutrophil leucocytes (see LEUCOCYTOSIS). body in the vagina. (See also UTERUS, DISEASES
(See also ABSCESS; BLOOD Composition; OF.)
INFLAMMATION; PHAGOCYTOSIS; WOUNDS.)
Leucotomy
Leucocytosis See PSYCHOSURGERY.
A condition in which the polymorphonuclear
LEUCOCYTES in the blood are increased in Leukaemia
number. It occurs in many different circum- Leukaemia is an umbrella term for several
stances, and forms a valuable means of diag- malignant disorders of white blood cells in
nosis in certain diseases; however, the condition which they proliferate in a disorganised man-
may occur as a normal reaction in certain con- ner. The disease is also characterised by
ditions (e.g. pregnancy, menstruation, and dur- enlargement of the SPLEEN, changes in the
ing muscular exercise). It is usually due to the BONE MARROW, and by enlargement of the
presence of inflammatory processes (see LYMPH glands all over the body. The condition
INFLAMMATION) the increased number of may be either acute or chronic.
L leucocytes helping to destroy the invading bac- According to the type of cells that predomin-
teria. Thus, during many acute infective dis- ate, leukaemia may be classified as acute or
eases, such as pneumonia, the number is greatly chronic lymphoblastic leukaemia or myeloid
increased. In all suppurative conditions (where leukaemia. Acute lymphoblastic leukaemia
PUS is formed) there is also a leucocytosis, and if (ALL) is mostly a disease of childhood and is
it seems that an ABSCESS is forming deep in the rare after the age of 25. Acute myeloid leu-
abdomen, or in some other site where it cannot kaemia is most common in children and young
be readily examined as, for example, an adults, but may occur at any age. Chronic
abscess resulting from APPENDICITIS the lymphatic leukaemia occurs at any age between
examination of a drop of blood gives a valuable 35 and 80, most commonly in the 60s, and is
aid in the diagnosis, and may be sufficient, in twice as common in men as in women. Chronic
the absence of other signs, to point out the myeloid leukaemia is rare before the age of 25,
urgent need of an operation. and most common between the ages of 30 and
65; men and women are equally affected.
Leucoderma Around 2,500 patients with acute leukaemia
Leucoderma, or leucodermia, is a condition of are diagnosed in the United Kingdom, with a
the skin in which areas of it become white, as similar number annually diagnosed with
the result of various skin diseases. chronic leukaemia.

Leucopenia Cause Both types of acute leukaemia seem to

A condition in which the number of LEUCO- arise from a MUTATION in a single white cell.
CYTES in the blood is greatly reduced by, say, The genetically changed cell then goes through
ANAEMIA or cancer. It is also a dangerous sign an uncontrolled succession of divisions result-
in severe SEPTICAEMIA. ing in many millions of abnormal white cells in
the blood, bone marrow and other tissues. Pos-
Leucoplakia sible causes are virus infection, chemical
See LEUKOPLAKIA. exposure, radiation and genetic background.
The cause of chronic lymphocytic leukaemia is
Leucorrhoea not known; the chronic myeloid version may
Discharge of mucus from the VAGINA. It may be have a genetic background.
whitish or yellowish and is normal in some
women, usually increasing before and after Symptoms In acute cases the patient is pale
MENSTRUATION. It is distinct from abnormal due to anaemia, may have a purpuric rash due
 Levodopa 409

to lack of platelets, and may have enlarged ticularly for the acute form of the disease.
lymphatic glands and spleen. The temperature Between 70 and 80 per cent of children with
is raised, and the condition may be mistaken acute lymphoblastic leukaemia may be cured;
for an acute infection (or may first become between 20 and 50 per cent of those with acute
apparent because the patient develops a severe myeloid leukaemia now have much-improved
infection due to a lack of normal white blood survival rates. Prognosis of patients with
cells). chronic lymphocytic leukaemia is often good,
In the chronic type of the disease the onset is depending on early diagnosis.
gradual, and the first symptoms which occasion
discomfort are either swelling of the abdomen Leuko-
and shortness of breath, due to painless See LEUCO-.
enlargement of the spleen; or the enlargement
of glands in the neck, armpits and elsewhere; or Leukoplakia
the pallor, palpitation, and other symptoms of A white plaque on mucous membranes caused
anaemia which often accompany leukaemia. by overgrowth of the tissues. It is occasionally a
Occasional bleeding from the nose, stomach, pre-cancerous condition.
gums or bowels may occur, and may be severe.
Generally, there is a slight fever. Leukotrienes
When the blood is examined microscopic- A group of naturally occurring, slow-reacting
ally, not only is there an enormous increase in substances (SRSS) which have powerful
the number of white cells, which may be multi- smooth-muscle stimulating properties, particu-
plied 30- or 60-fold, but various immature larly on bronchial smooth muscle. Leukotrienes
forms are also found. In the lymphatic form of are a metabolic derivative of PROSTAGLANDINS.
the disease, most white cells resemble lympho- Leukotriene receptor antagonists, such as mon-
cytes, which, in healthy blood, are present only telukast and zafirlukast, are drugs useful in
in small numbers. In the myeloid form, myelo- asthma. L
cytes, or large immature cells from the bone
marrow, which are never present in healthy Levallorphan Tartrate
blood, appear in large numbers, and there may An antidote to MORPHINE. It is usually given
also be large numbers of immature, nucleated intravenously.
erythrocytes.
Levamisole
Treatment This varies according to the type A drug used to treat ASCARIASIS. Its main
of leukaemia and to the particular condition of advantage seems to be in mass treatment, as one
the patient. Excellent results are being dose may prove effective. It is also being used in
obtained in the control of ALL using blood the treatment of a group of diseases of obscure
transfusions, CHEMOTHERAPY, RADIOTHERAPY origin, including CROHNS DISEASE and
and bone-marrow TRANSPLANTATION. In the RHEUMATOID ARTHRITIS. The drug is available
case of acute leukaemia, the drugs now being in the UK with certain restrictions.
used include MERCAPTOPURINE, METHOTREX-
ATE and CYCLOPHOSPHAMIDE. Blood transfu- Levator
sion and CORTICOSTEROIDS play an important (1) Any muscle that raises the organ or struc-
part in controlling the condition during the ture into which it is inserted.
period before a response to chemotherapy can (2) A surgical instrument for raising depressed
be expected. Chemotherapy has almost com- fragments of bone in a fracture, particularly a
pletely replaced radiotherapy in the treatment fracture of the skull.
of chronic leukaemia. For the myeloid form,
BUSULFAN is the most widely used drug, Levodopa
replaced by hydroxyurea, mercaptopurine, or A drug used in the treatment of PARKINSONISM.
one of the nitrogen mustard (see NITROGEN It is converted to DOPAMINE in the brain, cor-
MUSTARDS) derivatives in the later stages of the recting the deficiency which causes the disorder.
disease. For the lymphatic form, the drugs used Levodopa is often given with carbidopa or
are CHLORAMBUCIL, CYCLOPHOSPHAMIDE, and benserazide, both dopamine decarboxylase
the nitrogen mustard derivatives. inhibitors, to prevent its conversion to dopa-
mine in the body before it reaches the brain. It
Prognosis Although there is still no guaran- may cause nausea, HYPOTENSION or cardiac
teed cure, the outlook in both acute and DYSRHYTHMIA.
chronic leukaemia has greatly improved par-
 410 Levorphanol

Levorphanol CHLOROQUINE. Severe cases may require oral

A synthetic derivative of MORPHINE. It is an CORTICOSTEROIDS to control the eruption.
effective analgesic but, like morphine, is a drug
of addiction. Lidocaine
A local anaesthetic given by injection, previ-
LHRH ously called lignocaine. It is also used in the
Abbreviation for LUTEINISING HORMONE- treatment of certain disorders of cardiac rhythm
RELEASING HORMONE (LHRH), which is released known as ventricular arrhythmias which may be
by the PITUITARY GLAND. particularly dangerous following a coronary
thrombosis (see HEART, DISEASES OF).
LHRH Analogue
A synthetically produced agent with the same Life Expectancy
properties as LUTEINISING HORMONE- The number of years an individual can expect
RELEASING HORMONE (LHRH). to live. Life expectancy at birth in most western
countries is over 75 years for women (nearly 80
Libido in the UK in 1998) and over 70 for men (over
The natural desire for sexual intercourse. Lack 74 in the UK in 1998) a figure that has been
of desire or diminished libido may occur in any steadily rising as living standards have
general medical illness as well as in endocrine improved. The longer a person lives, the greater
diseases when there is a lack of production of is his or her life expectancy.
the sex hormones. The strength or weakness of
the sexual drive may be associated with psychi- Lifestyle Medicines
atric diseases; it may also be the result of certain Drugs used for non-health problems or for dis-
drugs. It must be distinguished from IMPO- orders that are in the grey area between a genu-
TENCE, where the desire for intercourse is nor- ine health need and a desire to change a life-
L mal but the performance is defective due to the style failing by the use of medication. Examples
inability to achieve or maintain an erection. are: SILDENAFIL CITRATE, which is prescribed
for men unable to achieve penile erection (erect-
Librium ile dysfunction); and ORLISTAT, a drug used to
See CHLORDIAZEPOXIDE. combat OBESITY.

Lice Ligaments
See PEDICULOSIS. Strong bands of fibrous tissue which serve to
bind together the bones entering into a joint. In
Lichen some cases they are cord-like; in others, flat-
Lichen, or lichenification, is a term used to tened bands whilst most joints are surrounded
describe a thickening of chronically inflamed by a fibrous capsule or capsular ligament. (See
skin to give a tree-bark-like appearance. JOINTS.)

Lichen simplex (neurodermatitis) is a form Ligation

of eczema (see DERMATITIS) perpetuated by con- Tying-off for example, of a blood vessel by
stant rubbing of the affected skin. Typically, completely encircling it with a tight band,
well-defined plaques occur on one or both sides usually of catgut or some other suture material.
of the nape of the neck, on the ulnar forearm
near the elbow, or on the sides of the calves. It is Ligature
often associated with emotional stress. A cord or thread used to tie around arteries in
order to stop the circulation through them, or
Lichen planus is a less common inflamma- to prevent escape of blood from their cut ends.
tion of the skin characterised by small, shiny, Ligatures are generally made of catgut or silk,
flat-topped violaceous papules which may and are tied with a reef-knot.
coalesce to form large plaques. Itching can be
intense. Typically seen on the flexor aspects of Light Reflex
the wrists, the lower back and on the legs below Pupillary constriction in the EYE in response to
the knees, it may also affect the mucous mem- light. The direct light reflex involves pupillary
branes of the mouth and lips. The cause is constriction in the eye into which a light is
unknown. While in some patients the disorder shone; the consensual light reflex is the pupil-
appears to be nervous or emotional in origin, it lary constriction that occurs in the other eye.
can be caused by certain drugs such as The afferent or inward pathway of the reflex is
 Liothyronine Acid 411

via the optic nerve, and the efferent or outward Linea Alba
pathway is via the occulomotor nerve. The line of fibrous tissue stretching down the
mid line of the belly from the lower end of the
Limbic System sternum to the pubic bone (see PUBIS). The linea
A circular, complex system of NERVE pathways alba gives attachment to the muscles of the wall
in the middle of the BRAIN. This connected of the stomach.
cluster of neuronal nuclei is involved in the
working of the AUTONOMIC NERVOUS SYSTEM, Linea Nigra
helping to control the expression of instinct During pregnancy, the LINEA ALBA becomes
and mood in activities of the motor systems pigmented and appears as a dark line down the
and the ENDOCRINE GLANDS of the body. The middle of the belly, and is called the linea nigra.
brain regions involved include the amygdala
(an almond-shaped basal ganglion deep in Linear Accelerator
each cerebral hemisphere), and the HYPO- See RADIOTHERAPY.
THALAMUS. If the limbic system is impaired by
injury or disease, the person may suffer Lingual
abnormal emotional responses such as Referring or related to the TONGUE: for
unprovoked rage, unreasonable fear and anx- example, the lingual nerve supplies sensation to
iety, depression, greater-than-normal sexual the tongue.
interest, and crying or laughing for no good
reason. Liniments
Liniments, or EMBROCATIONS, are oily mixtures
Limb Lengthening intended for external application by rubbing.
An orthopaedic procedure in which the length Their chief use is in the production of pain
of a limb, usually a leg, is increased. The bone is relief, particularly in rheumatic conditions.
surgically divided and slowly stretched in a spe- They may be highly toxic if taken orally. L
cial frame. The operation is usually done on
people with unequal leg lengths as a result of Linkage
injury or from PARALYSIS in childhood. A description that in GENETICS means circum-
Exceptionally, it may be done in both legs to stances in which two or more GENES lie near
help people of short stature. each other on a chromosome (see CHROMO-
SOMES) and so may well be inherited together.

Limbs, Artificial
See PROSTHESIS.
Linoleic Acid
An unsaturated fatty acid occurring widely in
the glycerides of plants. It is an essential nutri-
Lime-Juice ent for mammals, including humans.
A yellow liquid obtained by squeezing lime-
fruit, Citrus limetta. In common with lemon- Lint
juice, it is a rich source of vitamin C (168625 This was originally made of teased-out linen;
mg per 100 ml) and contains a large quantity of now it consists of a loose cotton fabric, one side
citric acid. It is used as a refreshing drink and as of which is fluffy, the other being smooth and
a preventive of, and remedy for, SCURVY. Lime- applied next to the skin when the surface is
juice which has been boiled, or preserved for a broken. Marine lint consists of tow impreg-
prolonged period, loses its anti-scorbutic nated with tar, and is used where large quan-
properties. tities of some absorbent and deodorising dress-
ing are required. Cotton lint is impregnated
Linctus with various substances, the most common
A term applied to any thick, syrupy medicine. being boracic lint. Lint containing perchloride
Most of these are remedies for excessive of iron (15 per cent) is valuable as a styptic (see
coughing. STYPTICS).

Lindane Liothyronine Acid

An insecticide used in SCABIES and lice infest- A preparation based on the thyroid (see THY-
ations (see PEDICULOSIS); however, head lice are ROID GLAND) hormone triiodothyronine,
now often resistant. Used excessively, lindane which is prescribed to replace the lack of natural
may be neurotoxic (damage the nervous thyroid hormone (hypothyroidism). The drug
system). is also used to treat goitre and cancer of the
 412 Lipaemia

thyroid gland. (See THYROID GLAND, DISEASES DISEASES OF). These drugs should be combined
OF.) with reducing other risk factors for raised lipid
concentrations, such as a high-fat diet, smoking
Lipaemia and obesity. Lipid-regulating drugs include
The presence of an excessive amount of FAT in STATINS, fibrates, anion-exchange resins, and
the blood. NICOTINIC ACID, which may be used singly or
in combination under careful medical supervi-
Lipase sion (see HYPERLIPIDAEMIA).
An ENZYME widely distributed in plants, and
present also in the liver and gastric and pan- Lipodystrophy
creatic juices, which breaks down fats to the A congenital maldistribution of FAT tissue.
constituent fatty acids and glycerol. Subcutaneous fat is totally absent from a por-
tion of the body and hypertrophied in the
Lipid remainder. Another form of lipodystrophy
A substance which is insoluble in water, but occurs at the site of INSULIN injections, but is
soluble in fat solvents such as alcohol and ether. much less frequently seen nowadays; the new,
The main lipid groups are the triglycerides, synthetic preparations of insulin are pure and
phospholipids, and glycolipids. They play an unlikely to cause this reaction, which was not
important role in nutrition, health (particularly uncommon with the older preparations.
in the functioning of the cell membranes, and Occasionally the converse occurs at the site of
the immune response), and disease (notably insulin injections, where the lipogenic action of
cardiovascular disease). There is a strong insulin stimulates the fat cells to hypertrophy.
correlation between the concentration of This can also be disfiguring and usually results
CHOLESTEROL in the blood (transported as from using the same site for injections too
lipoproteins) and the risk of developing frequently.
L ATHEROMA and coronary heart disease (see
HEART, DISEASES OF). Lipoproteins are classified Lipoid Factor
by their density and mobility, the chief groups An agent involved in the clotting mechanism of
being low-density (LDL) and high-density the blood. It helps in the activation of THROM-
(HDL). High SERUM concentrations of LDL BOPLASTIN in the blood PLASMA (see
increase the risk of cardiovascular disease, while COAGULATION).
HDL is thought to protect the vessel wall by
removing cholesterol, and has an inverse rela- Lipolysis
tionship to risk. The various serum lipid The enzymatic breaking-down of FAT.
abnormalities have been classified into five
groups, according to the cause and particular Lipoma
lipoprotein raised. Most important are type II A TUMOUR mainly composed of FAT. Such
(increased LDL, genetically determined) and tumours arise in almost any part of the body,
type IV (increased VLDL, associated with obes- developing in fibrous tissues particularly in
ity, diabetes, and excess alcohol). Various lipid- that beneath the skin. They are benign in
lowering drugs are available, but any drug nature, and seldom give any trouble beyond
treatment must be combined with a strict diet, that connected with their size and position. If
reduction of blood pressure, and cessation of large, they can be excised.
smoking.
Lipoproteins
Lipidosis Compounds containing lipids and proteins (see
Any disorder of LIPID metabolism in body cells. LIPID; PROTEIN). Most lipids in blood PLASMA
Some hereditary disorders cause deposition of are present in this form and are characterised
lipids within the brain. according to their densities: very low (VLDL),
intermediate (IDL), low (LD), high (HDL) and
Lipid-Regulating Drugs very high (VHDL). Concentrations of lipo-
These drugs reduce the amount of low-density proteins are key factors in assessing the risk of
LIPOPROTEINS, which transport CHOLESTEROL cardiovascular disease (see HEART, DISEASES OF).
and triglycerides (see TRIGLYCERIDE) in the
blood, or raise the concentration of high- Liposarcoma
density lipoproteins. The aim is to reduce the A rare malignant TUMOUR of adipose or fatty
progression of ATHEROSCLEROSIS and therefore tissue. It occurs most frequently in the thighs,
help prevent coronary heart disease (see HEART, buttocks or retro-peritoneum. The four main
 Lithium Carbonate 413

types are: well differentiated; myxoid; round Cancer of the lip sometimes occurs almost
cell; and pleomorphic (variety of forms). always in men, and usually on the lower lip. (See
also MOUTH, DISEASES OF.)
Liposomes
These are essentially tiny oil droplets consisting Liquor
of layers of fatty material, known as phospho- See SOLUTION.
lipid, separated by aqueous compartments.
Drugs can be incorporated into the liposomes, Liquorice
which are then injected into the bloodstream or The root of Glycyrrhiza glabra, a plant of south-
into the muscles, or given by mouth. Using this ern Europe and Asia. It is a mild expectorant
method of giving drugs, it is possible to protect (see EXPECTORANTS), but is mainly used to
them from being broken down in the body cover the taste of disagreeable and more power-
before they reach the part of the body where ful drugs. Solid and liquid extracts are made
their curative effect is required: for example, in from it, but the most commonly used prepar-
the liver or in a tumour. ation is compound liquorice powder, which
contains also senna and sulphur.
Liposuction
A surgical procedure, also called suction lipec- Listeriosis
tomy, for extracting unwanted accumulations A rare disease, although the causal organism,
of subcutaneous FAT with the use of a powerful Listeria monocytogenes, is widely distributed in
suction tube passed through the skin at differ- soil, silage, water, and various animals, with
ent sites. Widely used in cosmetic surgery to consequent risk of food contamination for
improve the contour of the body, particularly example, from unpasteurised soft cheese. Neo-
that of women, the technique can have nates are mainly affected often as a result of a
unwanted side-effects. mild or inapparent infection in the pregnant
mother. The disease presents in two main L
Lips forms: MENINGOENCEPHALITIS, or SEPTI-
These form a pair of curtains before the CAEMIA with enlarged LYMPH glands. Elderly
mouth, each composed of a layer of skin and adults occasionally develop the first form, while
of mucous membrane, between which lies a younger adults are more likely to develop a mild
considerable amount of fat and of muscle or even inapparent form. The disease is treated
fibres. with ANTIBIOTICS such as ampicillin (see PENI-
CILLIN) or CHLORAMPHENICOL.
Fissures coming on in cold weather are often
difficult to get rid of. Peeling and cracking of
the vermilion of the lips is common in those
Lithiasis
A general name applied to the formation of
exposed for long periods to wind and sunlight.
CALCULI and concretions in tissues or organs:
Treatment consists of the application of aque-
for example, cholelithiasis means the formation
ous cream. If the main cause is excessive
of calculi in the GALL-BLADDER.
exposure to sunlight in which case the lower
lip is mainly affected a protective cream
should be applied.
Lithium Carbonate
A drug widely used in the PROPHYLAXIS treat-
Herpes in the form of cold sores often ment of certain forms of MENTAL ILLNESS. The
develops on the lip as a result of a cold or other drug should be given only on specialist advice.
feverish condition, but quickly passes off (see The major indication for its use is acute
MANIA; it induces improvement or remission
HERPES SIMPLEX).
in over 70 per cent of such patients. In add-
Ulcers may form on the inner surface of the ition, it is effective in the treatment of manic-
lip, usually in consequence of bad teeth or of depressive patients (see MANIC DEPRESSION),
DYSPEPSIA. preventing both the manic and the depressive
episodes. There is also evidence that it lessens
Small cysts sometimes form on the inner aggression in prisoners who behave antisocially
surface of the lip, and are seen as little bluish and in patients with learning difficulties who
swellings filled with mucus; they are of no mutilate themselves and have temper
importance. tantrums.
Because of its possible toxic effects includ-
Hare-lip is a deformity sometimes present at ing kidney damage lithium must only be
birth (see PALATE, MALFORMATIONS OF). administered under medical supervision and
 414 Litholapaxy

with monitoring of the blood levels, as the gap gram of pure water at 4 C and 760 mm Hg
between therapeutic and toxic concentrations is pressure. For day-to-day measurement, 1 litre is
narrow. Due to the risk of its damaging the taken as being equal to 1,000 cubic centimetres
unborn child, it should not be prescribed, (cm3).
unless absolutely necessary, during pregnancy
particularly not in the first three months. Littles Disease
Mothers should not take it while breast feeding, A form of CEREBRAL PALSY.
as it is excreted in the milk in high concentra-
tions. The drug should not be taken with Liver
DIURETICS. The liver is the largest gland in the body, serv-
ing numerous functions, chiefly involving vari-
Litholapaxy ous aspects of METABOLISM.
Litholapaxy is the term applied to the operation
in which a stone in the URINARY BLADDER is Form The liver is divided into four lobes, the
crushed by an instrument introduced along the greatest part being the right lobe, with a small
URETHRA, and the fragments washed out left lobe, while the quadrate and caudate lobes
through a catheter (see CATHETERS). are two small divisions on the back and under-
surface. Around the middle of the under-
Lithotomy surface, towards the back, a transverse fissure
The operation of cutting for stone in the blad- (the porta hepatis) is placed, by which the hep-
der. The operation is of great historic interest, atic artery and portal vein carry blood into the
because more has probably been written about liver, and the right and left hepatic ducts
it in early times than about any other type of emerge, carrying off the BILE formed in the liver
surgery and because, for a long time, it to the GALL-BLADDER attached under the right
formed almost the only operation in which the lobe, where it is stored.
L surgeon dared to attack diseases of the internal
organs. Position Occupying the right-hand upper
part of the abdominal cavity, the liver is separ-
Lithotripsy ated from the right lung by the DIAPHRAGM and
Extracorporeal shock-wave lithotripsy (ESWL) the pleural membrane (see PLEURA). It rests on
causes disintegration of renal and biliary stones various abdominal organs, chiefly the right of
(see CALCULI) without physical contact, and is the two KIDNEYS, the suprarenal gland (see
therefore an attractive procedure for patients ADRENAL GLANDS), the large INTESTINE, the
and surgeons alike. DUODENUM and the STOMACH.
Shock waves generated outside the body can
be accurately focused with a reflector whilst the Vessels The blood supply differs from that of
patient is suspended in water, to facilitate the rest of the body, in that the blood collected
transmission of the waves. These are focused on from the stomach and bowels into the PORTAL
the calculus. The resultant fine fragments are VEIN does not pass directly to the heart, but is
passed spontaneously in the urine with min- first distributed to the liver, where it breaks up
imal, if any, discomfort. The procedure has into capillary vessels. As a result, some harmful
been shown to be safe, short and effective, and substances are filtered from the bloodstream
is most acceptable to patients. and destroyed, while various constituents of the
food are stored in the liver for use in the bodys
Litigation metabolic processes. The liver also receives the
See MEDICAL LITIGATION. large hepatic artery from the coeliac axis. After
circulating through capillaries, the blood from
Litmus both sources is collected into the hepatic veins,
Litmus, which is prepared from several lichens, which pass directly from the back surface of the
is a vegetable dye-substance, which on contact liver into the inferior vena cava.
with alkaline fluids becomes blue, and on con-
tact with acid fluids, red. Slips of paper, Minute structure The liver is enveloped in
impregnated with litmus, form a valuable test a capsule of fibrous tissue Glissons capsule
for the acidity of the secretions and discharges. from which strands run along the vessels and
penetrate deep into the organ, binding it
Litre together. Subdivisions of the hepatic artery,
A unit measurement of volume. One litre (l) is portal vein, and bile duct lie alongside each
equivalent to the volume occupied by one kilo- other, finally forming the interlobular vessels,
 Liver, Diseases of 415

serves several purposes: it excretes pigment, the

breakdown products of old red blood cells; the
bile salts increase fat absorption and activate
pancreatic lipase, thus aiding the digestion of
fat; and bile is also necessary for the absorption
of vitamins D and E.
The other important functions of the liver
are as follows:
In the EMBRYO it forms red blood cells, while
the adult liver stores vitamin B12, necessary
for the proper functioning of the bone mar-
row in the manufacture of red cells.
It manufactures FIBRINOGEN, ALBUMINS and
GLOBULIN from the blood.
It stores IRON and copper, necessary for the
manufacture of red cells.
It produces HEPARIN, and with the aid of
vitamin K PROTHROMBIN.
Its Kupffer cells form an important part of
the RETICULO-ENDOTHELIAL SYSTEM, which
breaks down red cells and probably manu-
factures ANTIBODIES.
Postions of liver, gall-bladder and connecting bile Noxious products made in the intestine and
ducts. absorbed into the blood are detoxicated in
the liver.
which lie between the lobules of which the It stores carbohydrate in the form of glyco- L
whole gland is built up. Each is about the size of gen, maintaining a two-way process: glucose
a pins head and forms a complete secreting glycogen.
unit; the liver is built up of hundreds of thou-
sands of such lobules. These contain small ves- CAROTENE, a plant pigment, is converted to
vitamin A, and B vitamins are stored.
sels, capillaries, or sinusoids, lined with stellate
KUPFFER CELLS, which run into the centre of
It splits up AMINO ACIDS and manufactures
UREA and uric acids.
the lobule, where they empty into a small cen-
tral vein. These lobular veins ultimately empty It plays an essential role in the storage and
metabolism of FAT.
into the hepatic veins. Between these capillaries
lie rows of large liver cells in which metabolic Liver, Diseases of
activity occurs. Fine bile capillaries collect the The LIVER may be extensively diseased without
bile from the cells and discharge it into the bile any obviously serious symptoms, unless the cir-
ducts lying along the margins of the lobules. culation through it is impeded, the outflow of
Liver cells are among the largest in the body, BILE checked, or neighbouring organs impli-
each containing one or two large round nuclei. cated. JAUNDICE is a symptom of several liver
The cells frequently contain droplets of fat or disorders, and is discussed under its separate
granules of GLYCOGEN that is, animal starch. heading. ASCITES, which may be caused by inter-
ference with the circulation through the portal
Functions The liver is, in effect, a large vein of the liver, as well as by other reasons, is
chemical factory and the heat this produces also considered separately. The presence of gall-
contributes to the general warming of the body. stones is a complication of some diseases con-
The liver secretes bile, the chief constituents of nected with the liver, and is treated under GALL-
which are the bile salts (sodium glycocholate BLADDER, DISEASES OF. For hydatid cyst of the
and taurocholate), the bile pigments (BILIRUBIN liver, see TAENIASIS. Liver diseases in a tropical
and biliverdin), CHOLESTEROL, and LECITHIN. environment are dealt with later in this section.
These bile salts are collected and formed in the
liver and are eventually converted into the bile Inflammation of the liver, or HEPATITIS,
acids. The bile pigments are the iron-free and may occur as part of a generalised infection or
globin-free remnant of HAEMOGLOBIN, formed may be a localised condition. Infectious hepa-
in the Kupffer cells of the liver. (They can also titis, which is the result of infection with a
be formed in the spleen, lymph glands, bone virus, is one of the most common forms. Many
marrow and connective tissues.) Bile therefore different viruses can cause hepatitis, including
 416 Liver, Diseases of

that responsible for glandular fever (see MONO- amoebic DYSENTERY, appearing sometimes late
NUCLEOSIS). Certain spirochaetes may also be in the disease even after the diarrhoea is cured
the cause, particularly that responsible for (see below). It may also follow upon inflamma-
LEPTOSPIROSIS, as can many drugs. Hepatitis tion of the liver due to other causes. In the case
may also occur if there is obstruction of the BILE of an amoebic abscess, treatment consists of oral
DUCT, as by a gall-stone. metronidazole.

Cirrhosis of the liver A disorder caused by Acute hepatic necrosis is a destructive

chronic damage to liver cells. The liver develops and often fatal disease of the liver which is very
areas of fibrosis or scarring; in response, the rare. It may be due to chemical poisons, such as
remaining normal liver cells increase and form carbontetrachloride, chloroform, phosphorus
regeneration nodules. Those islands of normal- and industrial solvents derived from benzene. It
ity, however, suffer from inadequate blood sup- may also be the cause of death in cases of poi-
ply, thus adversely affecting liver function. soning with fungi. Very occasionally, it may be
Alcohol is the most common cause of cirrhosis a complication of acute infectious hepatitis.
in the United Kingdom and the USA, and the
incidence of the disorder among women in the Cancer of the liver is not uncommon,
UK has recently risen sharply as a consequence although it is rare for the disease to begin in the
of greater consumption of alcohol by young liver the involvement of this organ being usu-
women in the latter decades of the 20th cen- ally secondary to disease situated somewhere in
tury. In Africa and many parts of Asia, infection the stomach or bowels. Cancer originating in
with hepatitis B virus is a common cause. Cer- the liver is more common in Asia and Africa. It
tain drugs for example, PARACETAMOL may usually arises in a fibrotic (or cirrhotic) liver and
damage the liver if taken in excess. Unusual in carriers of the hepatitis B virus. There is great
causes of cirrhosis include defects of the bile emaciation, which increases as the disease pro-
L ducts, HAEMOCHROMATOSIS (raised iron gresses. The liver is much enlarged, and its mar-
absorption from the gut), CYSTIC FIBROSIS, car- gin and surface are rough, being studded with
diac cirrhosis (the result of heart failure causing hard cancer masses of varying size, which can
circulatory congestion in the liver), and often be felt through the abdominal wall. Pain
WILSONS DISEASE (raised copper absorption). may be present. Jaundice and oedema often
appear.
Symptoms Some people with cirrhosis have
no signs or symptoms and the disease may be Liver disease in the tropics
diagnosed at a routine medical examination. ACUTE LIVER DISEASE The hepatitis viruses (A
Others may develop jaundice, OEDEMA (includ- F) are of paramount importance. Hepatitis E
ing ascites fluid in the abdomen), fever, con- (HEV) often produces acute hepatic failure in
fusion, HAEMATEMESIS (vomiting blood), loss pregnant women; extensive epidemics trans-
of appetite and lethargy. On examination, cir- mitted by contaminated drinking-water sup-
rhotic patients often have an enlarged liver and/ plies have been documented. HBV, especially
or SPLEEN, and HYPERTENSION. Liver function in association with HDV, also causes acute liver
tests, cholangiography (X-ray examination of failure in infected patients in several tropical
the bile ducts) and biopsy of liver tissue will countries: however, the major importance of
help to reach a diagnosis. HBV is that the infection leads to chronic liver
disease (see below). Other hepatotoxic viruses
Treatment Nothing can be done to repair a include the EPSTEIN BARR VIRUS, CYTO-
cirrhosed organ, but the cause, if known, must MEGALOVIRUS (CMV), the flavivirus causing
be removed and further advance of the process YELLOW FEVER, Marburg/Ebola viruses, etc.
thus prevented. In the case of the liver, a high- Acute liver disease also occurs in the presence of
protein, high-carbohydrate, low-fat diet is several acute bacterial infections, including
given, supplemented by liver extract and vit- Salmonella typhi, brucellosis, leptospirosis,
amins B and K. The consumption of alcohol syphilis, etc. The complex type of jaundice
should be banned. In patients with liver failure associated with acute systemic bacterial infec-
and a poor prognosis, liver TRANSPLANTATION tion especially pneumococcal PNEUMONIA
is worthwhile but only after careful and pyomiositis assumes a major importance
consideration. in many tropical countries, especially those in
Africa and in Papua New Guinea. Of protozoan
Abscess of the liver When an ABSCESS infections, plasmodium falciparum malaria,
develops in the liver, it is usually a result of LEISHMANIASIS, and TOXOPLASMOSIS should be
 Lobe 417

considered. Ascaris lumbricoides (the round- Liver Fluke

worm) can produce obstruction to the biliary Fasciola hepatica is a parasite infesting sheep and
system. occasionally invading the bile ducts and liver of
CHRONIC LIVER DISEASE Long-term disease is humans (see FASCIOLIASIS).
dominated by sequelae of HBV and HCV
infections (often acquired during the neonatal Liver Spots
period), both of which can cause chronic A misnomer applied to the brown MACULES
active hepatitis, cirrhosis, and hepatocellular often seen on the backs of the hands of those
carcinoma (hepatoma) one of the worlds chronically exposed to sunlight (see LENTIGO).
most common malignancies. Chronic liver They have no connection with any liver
disease is also caused by SCHISTOSOMIASIS disorder.
(usually Schistosoma mansoni and S. japoni-
cum), and acute and chronic alcohol inges- Living Will
tion. Furthermore, many local herbal remedies Also known as an advance directive or advance
and also orthodox chemotherapeutic com- statement about medical treatment. This is a
pounds (e.g. those used in tuberculosis and means of exercising choice in advance for
leprosy) can result in chronic liver disease. patients who suspect that they will suffer men-
HAEMOSIDEROSIS is a major problem in tal impairment and become unable to speak for
southern Africa. Hepatocytes contain excessive themselves. Advance statements can have legal
iron derived primarily from an excessive force if made by an informed and competent
intake, often present in locally brewed beer; adult, clearly refusing some or all future medical
however, a genetic predisposition seems likely. treatment once that individual has irrevocably
Indian childhood cirrhosis associated with lost mental capacity. Some statements intend to
an excess of copper is a major problem in give other instructions, such as requesting cer-
India and surrounding countries. Epidemi- tain treatments: these can be helpful in clarify-
ological evidence shows that much of the ing the patientss wishes, but only a clear refusal L
copper is derived from copper vessels used to of treatment is legally binding in most of the
store milk after weaning. Veno-occlusive dis- UK. (In Scotland, patients have some legal
ease was first described in Jamaica and is powers to use an advance statement to nomin-
caused by pyrrolyzidine alkaloids (present in ate another person to act as a proxy decision-
bush-tea). Several HIV-associated opportun- maker.)
istic infections can give rise to hepatic disease As there is no statute defining the scope and
(see AIDS/HIV). limits of advance statements in the UK, their
A localised (focal) form of liver disease in all legal status depends principally on case prece-
tropical/subtropical countries results from inva- dents. As well as written documents, competent
sive Entamoeba histolytica infection (amoebic patients can make equally valid advance oral
liver abscess); serology and imaging techniques refusals which should be recorded in the med-
assist in diagnosis. Hydatidosis also causes local- ical notes. Some health professionals or health
ised liver disease; one or more cysts usually facilities may have a conscientious objection (see
involve the right lobe of the liver. Serological ETHICS) to the concept of withdrawing life-
tests and imaging techniques are of value in prolonging treatment from incompetent
diagnosis. Whilst surgery formerly constituted patients, even at the patients advance request.
the sole method of management, prolonged Such objections need to be made known to
courses of albendazole and/or praziquantel patients well in advance of a living will becom-
have now been shown to be effective; however, ing eligible for implementation, so that the
surgical intervention is still required in some patient can make other arrangements. The Brit-
cases. ish Medical Association has issued a code of
Hepato-biliary disease is also a problem in practice on the subject; this provides widely
many tropical/subtropical countries. In south- approved guidance on various facets of drafting,
east Asia, Clonorchis sinensis and Opisthorchis storing, witnessing and implementing advance
viverini infections cause chronic biliary-tract statements. It is also dealt with in the GMC
infection, complicated by adenocarcinoma of document on withdrawing treatment.
the biliary system. Praziquantel is effective
chemotherapy before advanced disease ensues. Loa
Fasciola hepatica (the liver fluke) is a further See LOIASIS.
hepato-biliary helminthic infection; treatment
is with bithionol or triclabendazole, praziquan- Lobe
tel being relatively ineffective. The term applied to the larger divisions of
 418 Lobectomy

various organs, such as to the four lobes of the vous system is paralysed. Several diseases can
LIVER, the three lobes of the right and the two cause this syndrome, which results from inter-
lobes of the left lung, which are separated by ruption of some of the nerve tracts between the
fissures from one another (see LUNGS), and to mid brain and the pons (see BRAIN). Sometimes
the lobes or superficial areas into which the the syndrome is caused by severe damage to
BRAIN is divided. The term lobar is applied to muscles or the nerves enervating them. Locked-
structures which are connected with lobes of in syndrome may sometimes be confused with a
organs, or to diseases which have a tendency to PERSISTENT VEGETATIVE STATE (PVS).
be limited by the boundaries of lobes, such as
lobar PNEUMONIA. Lockjaw
A painful spasm of the JAW muscles, making it
Lobectomy hard to open the mouth. It is a prominent
The operation of cutting out a lobe of the lung symptom of TETANUS and was once the popular
in such diseases as abscess of the lung and bron- name for this condition.
chiectasis and carcinoma (see LUNGS, DISEASES
OF). Locomotor Ataxia
The uncoordinated movements and unsteady
Lobotomy lurching gait that occurs in the tertiary stage of
Lobotomy is the cutting of a lobe of the BRAIN. untreated SYPHILIS.
(See also PSYCHOSURGERY.)
Locum Tenens
Lobule A doctor who stands in for another.
The term applied to a division of an organ
smaller than a lobe: for example, the lobules of Lofexidine
the lung are of the size of millet seeds (see An opioid antagonist drug used to modify the
L LUNGS); those of the LIVER, slightly larger. Lob- symptoms of addicted patients undergoing
ules form the smallest subdivisions or units of opioid-withdrawal treatment.
an organ, each lobule being similar to the
others, of which there may be perhaps several Logorrhoea
hundred thousand in the organ. Logorrhoea is the technical term for garrulous-
ness (chatterbox) a feature which may be
Local Anaesthesia exaggerated in certain states of mental
Loss of sensation produced in a part of the body instability.
to stop pain while a person is examined,
investigated or treated (see also ANAESTHESIA). Loiasis
The anaesthesia is effected by giving drugs in a Loiasis is the disease caused by the filarial worm
local area temporarily to stop the action of Loa loa, a thread-like worm which differs from
pain-carrying nerve fibres. To anaesthetise a W. bancrofti in that it is shorter and thicker, and
large area, a nerve block is done. Various drugs is found in the bloodstream during the day, not
are used, depending on the depth and length of at night. It is transmitted by the mango fly,
local anaesthesia required. Chrysops dimidiata, but other flies of this genus
can also transmit it. It is confined to West and
Lochia Central Africa. The characteristic feature of the
Lochia is the discharge which takes place during disease is the appearance of fugitive swellings
the first week or two after childbirth. During which may arise anywhere in the body in the
the first four days it consists chiefly of blood; course of the worms migration through it:
after the fifth day the colour should become these are known as Calabar swellings. The
paler, and after the first week the quantity worm is often found in the eye, hence the old
should diminish. If the discharge becomes name of the worm in Africa the eye worm.
smelly, it may indicate an infection and Diethylcarbamazine is the treatment for this
immediate investigation and treament are form of FILARIASIS.
necessary. (See also PUERPERIUM.)
Loin
Locked-In Syndrome The name applied to the part of the back
This describes a condition in which a patient is between the lower ribs and the pelvis. (For pain
awake and retains the power of sense percep- in the loins, see BACKACHE; LUMBAGO.)
tion, but is unable to communicate except by
limited eye movements because the motor ner-
 Lumbago 419

Long-Sight with sugar, gum, glycerin-jelly or fruit-paste.

Also known as hypermetropia: see under EYE, They are used in various affections of the
DISORDERS OF Errors of refraction. mouth and throat, being sucked and slowly dis-
solved by the saliva, which brings the drugs they
Loop Diuretics contain into contact with the affected surface.
Drugs used in pulmonary oedema (excess fluid Some of the substances used in lozenges are
in the lungs) caused by failure of the left VEN- benzalkonium (disinfectant), benzocaine
TRICLE of the HEART. DIURETICS cause an (analgesic), betamethasone (corticosteroid),
increase in excretion of URINE, thus reducing bismuth (disinfectant), formaldehyde (dis-
the amount of fluid in the body. Intravenous infectant), hydrocortisone (corticosteroid),
administration of loop diuretics relieves liquorice, and penicillin (antibiotic).
patients breathlessness. They work by inhibit-
ing resorption of fluid in the renal tubule loops LSD
of the KIDNEYS. Frusemide and bumetanide are See LYSERGIC ACID DIETHYLAMIDE (LSD).
commonly used loop diuretic drugs that act
quickly and last for six hours so that they can be Lucid Interval
given twice in 24 hours without disturbing the A temporary restoration of consciousness after a
patients sleep. person has been rendered unconscious from a
blow to the head. The victim subsequently
Loperamide relapses into COMA. This is a sign of raised
A drug that reduces the motility of the GASTRO- INTRACRANIAL PRESSURE from arterial bleeding
INTESTINAL TRACT. It is of limited use as an and indicates that surgery may be required to
adjunct to fluid replacement in diarrhoea in control the intracranial haemorrhage. (See also
adults, and is sometimes used in chronic non- GLASGOW COMA SCALE.)
infective diarrhoea in children.
Ludwigs Angina L
Lorazepam An uncommon bacterial infection affecting the
A benzodiazepine tranquilliser (see BENZO- floor of the mouth. It can spread to the throat
DIAZEPINES), shown to be of limited use in the and become life-threatening. Usually caused by
short-term treatment of anxiety or insomnia, infected gums or teeth, it causes pain, fever and
in STATUS EPILEPTICUS, or for perioperative use. swelling, resulting in difficulty in opening the
Its use is not recommended for children. As with mouth or swallowing. Urgent treatment with
other benzodiazepines, the smallest possible dose ANTIBIOTICS is called for, otherwise the patient
should be given for the shortest possible time, as may need a TRACHEOSTOMY to relieve breath-
DEPENDENCE is a well-recognised danger. ing problems.

Lordosis Lugols Solution

An unnatural curvature of the spine forwards. It A compound solution of iodine and potassium
occurs chiefly in the lumbar region, where the iodide used in the preoperative preparation of
natural curve is forwards, as the result of muscu- patients with thyrotoxicosis (see THYROID
lar weakness, spinal disease, etc. (See SPINAL GLAND, DISEASES OF). The solution is taken
COLUMN.) orally.

Lotions Lumbago
Fluid preparations intended for bringing into Pain in the lower (lumbar) region of the back. It
contact with, or for washing, the external sur- may be muscular, skeletal or neurological in
face of the body. Lotions are generally of a origin. A severe form associated with SCIATICA
watery or alcoholic composition, and many of may be due to a prolapsed INTERVERTEBRAL
them are known as liquors. Those external DISC. Less severe forms may be caused by
applications which are of an oily nature, and OSTEOARTHRITIS of the spine, a trapped nerve,
intended to be rubbed into the surface, are inflammation of connective tissue, or may fol-
known as liniments. low an old injury.
The treatment will depend upon the cause,
Louse but mild lumbago will usually respond to
See PEDICULOSIS. NON-STEROIDAL ANTI-INFLAMMATORY DRUGS
(NSAIDS) and the application of warmth. Suf-
Lozenges ferers should remember to bend their knees
These are small tablets containing drugs mixed rather than their backs when lifting objects.
 420 Lumbar

Moderate activity rather than bed rest is procedure should not be done too rapidly or the
recommended for most patients. subject may develop a severe headache. Exam-
ination of the cerebrospinal fluid helps in the
Lumbar diagnosis and investigation of disorders of the
A term used to denote structures in, or diseases brain and spinal cord for example, MENIN-
affecting, the region of the loins (see LOIN) as, GITIS and SUBARACHNOID HAEMORRHAGE.
for example, the lumbar vertebrae, lumbar When using the procedure to inject drugs into
abscess. the CSF, the operator must take care to inject
only those agents specifically produced for CSF
Lumbar Puncture injection. Deaths have occurred because the
A procedure for removing CEREBROSPINAL wrong drug has been injected, and there have
FLUID (CSF) from the spinal canal in the LUM- been demands for specialised equipment and
BAR region in order: (1) to diagnose disease of strict procedures that will prevent such tragedies.
the nervous system; (2) to introduce medic-
aments spinal anaesthetics or drugs. A hollow Lumbar Sympathectomy
needle is inserted into the lower section of the Destruction of the LUMBAR chain of sympa-
space around the SPINAL CORD (see diagram) thetic nerves (see NERVOUS SYSTEM) by means of
and the cerebrospinal fluid withdrawn. The surgery, DIATHERMY or injection of chemicals
(phenol or alcohol). The technique is used to
improve the blood flow to the leg in patients
with peripheral vascular disease, and to treat
some types of chronic leg pain. It has only
limited success.

Lumbar Vertebra
There are five lumbar vertebrae in the lower
L SPINAL COLUMN between the thoracic vertebrae
and the sacrum.

Lumbricus
Lumbricus is a name sometimes applied to the
roundworm, or Ascaris lumbricoides. (See
ASCARIASIS.)

Lumen
(1) The space enclosed by a tubular structure or
hollow organ (e.g. the gastrointestinal tract or
urinary bladder).
(2) The SI unit of luminous flux (1 lumen [1m]
= the amount of light emitted per second in a
unit solid angle of 1 steradian by a 1-candela
point source).

Lumpectomy
An operation for suspected breast cancer (see
BREASTS, DISEASES OF), in which the tumour is
removed from the breast rather than with it (see
MASTECTOMY).

Lunatic
An out-of-date and now derogatory term
The patient lies on his/her left side with the back
applied to people of disordered mind, because
on the edge of the bed and the hips and knees
flexed as shown in this diagram. The needle is
lunacy was supposed at one time to be largely
inserted through the skin between the processes of influenced by the moon. (See MENTAL ILLNESS.)
the third and fourth lumbar vertebrae. The needle
is then passed through the spinal ligaments and Lung Volumes
the dura into the subarachnoid space which con- The volume of air within the LUNGS changes
tains the spinal fluid. A sample of fluid is slowly with the respiratory cycle (see RESPIRATION).
withdrawn. The volumes defined in the following table can
 Lungs, Diseases of 421

be measured, and may be useful indicators of action of the heart. Furthermore, both lungs are
some pulmonary diseases. connected by blood vessels to the heart. The
Normal values for a 60 kg man are (in ml): pulmonary artery passes from the right ventricle
and divides into two branches, one of which
TLC 5,0006,000 runs straight outwards to each lung, entering its
TV 400600 substance along with the bronchial tube at the
IRV 3,3003,750 hilum or root of the lung. From this point also
ERV 9501,200 emerge the pulmonary veins, which carry the
RV 1,2001,700 blood oxygenated in the lungs back to the left
VC 3,4004,800 atrium.
FRC 2,3002,600
Fine structure of lungs Each main bron-
Total lung capacity (TLC) The volume of chial tube, entering the lung at the root, divides
air that can be held in the lungs at maximum into branches. These subdivide again and again,
inspiration. to be distributed all through the substance of
the lung until the finest tubes, known as
Tidal volume (TV) The volume of air taken respiratory bronchioles, have a width of only
into and expelled from the lungs with each 025 mm (1/100 inch). All these tubes consist
breath. of a mucous membrane surrounded by a fibrous
sheath. The surface of the mucous membrane
Inspiratory reserve volume (IRV) The comprises columnar cells provided with cilia
volume of air that can still be inspired at the (hair-like structures) which sweep mucus and
end of a normal quiet inspiration. unwanted matter such as bacteria to the
exterior.
Expiratory reserve volume (ERV) The The smallest divisions of the bronchial tubes,
volume of air that can still be expired at the end or bronchioles, divide into a number of tortu-
of a normal quiet expiration. L
ous tubes known as alveolar ducts terminating
eventually in minute sacs, known as alveoli, of
Residual volume (RV) The volume of air which there are around 300 million.
remaining in the lungs after a maximal The branches of the pulmonary artery
expiration. accompany the bronchial tubes to the furthest
recesses of the lung, dividing like the latter
Vital capacity (VC) The maximum into finer and finer branches, and ending in
amount of air that can be expired after a max- a dense network of capillaries. The air in
imal inspiration. the air-vesicles is separated therefore from the
blood only by two delicate membranes: the
Functional residual capacity wall of the air-vesicle, and the capillary wall,
(FRC) The volume of air left in the lungs at through which exchange of gases (oxygen and
the end of a normal quiet expiration. carbon dioxide) readily takes place. The essen-
tial oxygenated blood from the capillaries is
Lungs collected by the pulmonary veins, which also
Positioned in the chest, the lungs serve primar- accompany the bronchi to the root of the
ily as respiratory organs (see RESPIRATION), also lung.
acting as a filter for the blood. The lungs also contain an important system
of lymph vessels, which start in spaces situated
Form and position Each lung is a sponge- between the air-vesicles and eventually leave the
like cone, pink in children and grey in adults. lung along with the blood vessels, and are con-
Its apex projects into the neck, with the base nected with a chain of bronchial glands lying
resting on the DIAPHRAGM. Each lung is near the end of the TRACHEA.
enveloped by a closed cavity, the pleural cavity,
consisting of two layers of pleural membrane Lungs, Diseases of
separated by a thin layer of fluid. In healthy Various conditions affecting the LUNGS are
states this allows expansion and retraction as dealt with under the following headings:
breathing occurs. ASTHMA; BRONCHIECTASIS; CHEST, DEFORM-
ITIES OF; CHRONIC OBSTRUCTIVE PULMONARY
Heart/lung connections The HEART lies DISEASE (COPD); COLD, COMMON; EMPHYSEMA;
in contact with the two lungs, so that changes EXPECTORATION; HAEMOPTYSIS; HAEMOR-
in lung volume inevitably affect the pumping RHAGE; OCCUPATIONAL HEALTH, MEDICINE
 422 Lungs, Diseases of

AND DISEASES; PLEURISY; PNEUMONIA; PUL- and supporting the patient by providing
MONARY EMBOLISM; TUBERCULOSIS. oxygen.

Inflammation of the lungs is generally Collapse of the lung may occur due to
known as PNEUMONIA, when it is due to infec- blockage of a bronchial tube by tumour, foreign
tion; as ALVEOLITIS when the inflammation is body or a plug of mucus which may occur in
immunological; and as PNEUMONITIS when it is bronchitis or pneumonia. Air beyond the
due to physical or chemical agents. blockage is absorbed into the circulation, caus-
ing the affected area of lung to collapse. Col-
Abscess of the lung consists of a collec- lapse may also occur when air is allowed into
tion of PUS within the lung tissue. Causes the pleural space the space between the lining
include inadequate treatment of pneumonia, of the lung and the lining of the inside of the
inhalation of vomit, obstruction of the bron- chest wall. This is called a pneumothorax and
chial tubes by tumours and foreign bodies, may occur following trauma, or spontaneously
pulmonary emboli (see EMBOLISM) and septic for example, when there is a rupture of a sub-
emboli. The patient becomes generally unwell pleural air pocket (such as a cyst) allowing a
with cough and fever. BRONCHOSCOPY is fre- communication between the airways and the
quently performed to detect any obstruction to pleural space. Lung collapse by compression
the bronchi. Treatment is with a prolonged may occur when fluid collects in the pleural
course of antibiotics. Rarely, surgery is space (pleural effusion): when this fluid is
necessary. blood, it is known as a haemothorax; if it is due
to pus it is known as an empyema. Collections
Pulmonary oedema is the accumulation of air, blood, pus or other fluid can be removed
of fluid in the pulmonary tissues and air spaces. from the pleural space by insertion of a chest
This may be caused by cardiac disease (heart drain, thus allowing the lung to re-expand.
L failure or disease of heart valves see below, and
HEART, DISEASES OF) or by an increase in the Tumours of the lung are the most com-
permeability of the pulmonary capillaries allow- mon cause of cancer in men and, along with
ing leakage of fluid into the lung tissue (see breast cancer, are a major cause of cancer in
ACUTE RESPIRATORY DISTRESS SYNDROME women. Several types of lung cancer occur, the
(ARDS)). most common being squamous cell carcinoma,
small- (or oat-) cell carcinoma, adenocarci-
Heart failure (left ventricular failure) can be noma, and large-cell carcinoma. All but the
caused by a weakness in the pumping action of adenocarcinoma have a strong link with smok-
the HEART leading to an increase in back pres- ing. Each type has a different pattern of growth
sure which forces fluid out of the blood vessels and responds differently to treatment. More
into the lung tissue. Causes include heart than 30,000 men and women die of cancer of
attacks and HYPERTENSION (high blood pres- the trachea, bronchus and lung annually in
sure). Narrowed or leaking heart valves hinder England and Wales.
the flow of blood through the heart; again, this The most common presenting symptom is
produces an increase in back pressure which cough; others include haemoptisis (coughing
raises the capillary pressure in the pulmonary up blood), breathlessness, chest pain, wheezing
vessels and causes flooding of fluid into the and weight loss. As well as spreading locally in
interstitial spaces and alveoli. Accumulation of the lung the rate of spread varies lung cancer
fluid in lung tissue produces breathlessness. commonly spawns secondary growths in the
Treatments include DIURETICS and other drugs liver, bones or brain. Diagnosis is confirmed by
to aid the pumping action of the heart. Surgical X-rays and bronchoscopy with biopsy.
valve replacement may help when heart failure
is due to valvular heart disease. Treatment Treatment for the two main cat-
egories of lung cancer small-cell and non-
Acute respiratory distress syn- small-cell cancer is different. Surgery is the
drome Formerly known as adult respiratory only curative treatment for the latter and
distress syndrome (ARDS), this produces pul- should be considered in all cases, even though
monary congestion because of leakage of fluid fewer than half undergoing surgery will survive
through pulmonary capillaries. It complicates a five years. In those patients unsuitable for sur-
variety of illnesses such as sepsis, trauma, aspir- gery, radical RADIOTHERAPY should be con-
ation of gastric contents and diffuse pneu- sidered. For other patients the aim should be
monia. Treatment involves treating the cause the control of symptoms and the maintenance
 Lymph 423

of quality of life, with palliative radiotherapy GLAND which stimulates OVULATION, matur-
one of the options. ation of the CORPUS LUTEUM, and the synthesis
Small-cell lung cancer progresses rapidly, and of progesterone by the ovary (see OVARIES) and
untreated patients survive for only a few testosterone by the testis (see TESTICLE).
months. Because the disease is often widespread
by the time of diagnosis, surgery is rarely an Luteinising Hormone-Releasing
option. All patients should be considered for Hormone (LHRH)
CHEMOTHERAPY which improves symptoms A natural hormone released by the HYPO-
and prolongs survival. THALAMUS gland in the BRAIN. It stimulates the
release of GONADOTROPHINS from the PITUIT-
Wounds of the lung may cause damage to ARY GLAND; these control the production of the
the lung and, by admitting air into the pleural sex hormones (see ANDROGEN; OESTROGENS).
cavity, cause the lung to collapse with air in the
pleural space (pneumothorax). This may Lux
require the insertion of a chest drain to remove The unit of illumination. The abbreviation is
the air from the pleural space and allow the lx.
lung to re-expand. The lung may be wounded
by the end of a fractured rib or by some sharp Luxation
object such as a knife pushed between the ribs. Another word for dislocation (see
DISLOCATIONS).
Lupus
This is the Latin word for wolf, and a term Lycanthropy
applied to certain chronic skin diseases which Morbid delusion that one is a wolf.
can destroy skin, underlying cartilage and even
bone to cause serious deformity if uncontrolled. Lying-In
Lupus vulgaris is a form of TUBERCULOSIS
See PREGNANCY AND LABOUR. L
of the skin. It typically begins in childhood and Lyme Disease
may spread slowly for decades if untreated. The This comprises ARTHRITIS associated with skin
face and neck are the usual sites. In untreated rashes, fever and sometimes ENCEPHALITIS or
disease, large, well-demarcated areas may be carditis (inflammation of the heart). It is caused
affected with redness, scaling and thickening. If by a SPIROCHAETE which is transmitted by tick
the affected skin is blanched by pressure, bite. Treatment is with antibiotics.
yellow-brown foci may be observed the so-
called apple-jelly nodules. The disease causes Lymph
extensive scarring as it spreads and may destroy Lymph is the fluid which circulates in the
cartilage in its path for example, on the nose lymphatic vessels of the body. It is a colourless
or ear causing gross deformity. The disease fluid, like blood PLASMA in composition, only
was common in the UK up to 50 years ago, but rather more watery. It contains salts similar to
is now rare. It is treated with a combination of those of blood plasma, and the same proteins,
tuberculostatic drugs. although in smaller amount: FIBRINOGEN,
Lupus erythematosus is an autoimmune serum albumin (see ALBUMINS), and serum
GLOBULIN. It also contains lymphocytes
disease which can affect skin or internal organs.
(white blood cells), derived from the glands. In
Discoid lupus erythematosus (DLE) In some lymphatic vessels, the lymph contains,
this disease, only the skin is affected. Sharply after meals, a great amount of FAT in the form
defined red, scaly and eventually atrophic of a fine milky emulsion. These are the vessels
patches appear on the face, especially on the which absorb fat from the food passing down
nose and cheeks. ALOPECIA with scarring is seen the INTESTINE, and convey it to the thoracic
if the scalp is affected. The condition is aggra- duct; they are called lacteals because their con-
vated by sunlight. Topical CORTICOSTEROIDS tents look milky (see CHYLE).
are helpful. The lymph is derived, initially, from the
blood, the watery constituents of which exude
Systemic lupus erythematosus (SLE) through the walls of the CAPILLARIES into the
See separate dictionary entry. tissues, conveying material for the nourishment
of the tissues and absorbing waste products.
Luteinising Hormone The spaces in the tissues communicate with
A hormone secreted by the anterior PITUITARY lymph capillaries, which have a structure similar
 424 Lymphadenectomy

to that of the capillaries of the blood-vessel sys- Lymphangiography

tem, being composed of delicate flat cells joined A procedure whereby the LYMPHATICS and
edge to edge. These unite to form fine vessels, lymphatic glands can be rendered visible on
resembling minute veins in structure, called X-ray films by means of the injection of
lymphatics, which ramify throughout the body, radio-opaque substances. It has now been
passing through lymphatic glands and ultim- replaced largely by magnetic resonance imaging
ately discharging their contents into the jugular (MRI).
veins in the root of the neck. Other lymph ves-
sels commence in great numbers as minute Lymphangioma
openings on the surface of the PLEURA and An uncommon, non-malignant tumour occur-
PERITONEUM, and act as drains for these other- ring in the skin or the tongue. It comprises an
wise closed cavities. When fluid is effused into abnormal collection of lymph vessels and tends
these cavities as in a pleural effusion, for to be present from birth. Sometimes it disap-
example its absorption takes place through pears spontaneously, but it may need surgical
the lymphatic vessels. The course of these ves- removal.
sels is described under the entry on GLAND.
Lymph circulates partly by reason of the Lymphangitis
pressure at which it is driven through the walls Inflammation situated in the lymphatic vessels.
of the blood capillaries, but mainly in con-
sequence of incidental forces. The lymph capil- Lymphatics
laries and vessels are copiously provided with Vessels which convey the LYMPH. (For an
valves, which prevent any back flow of lymph, account of their arrangement, see GLAND.)
and every time these vessels are squeezed (as by
the contraction of a muscle, or movement of a Lymph Nodes
limb) the lymph is pumped along. Swellings which occur at various points in the
L The term lymph is also applied to the serous lymphatic system through which LYMPH drains.
fluid contained in the vesicles which develop as They consist of a cortex, medulla and lymph
the result of vaccination, and used for the sinuses and have two main functions: (1) the
purpose of vaccinating other individuals. interception and removal of abnormal or for-
eign material from the lymph; (2) the produc-
Lymphadenectomy tion of immune responses (see IMMUNITY). The
Surgical removal of the LYMPH NODES. The lymph nodes become enlarged when the area of
procedure is usually carried out when cancer the body which they drain is the site of infec-
has infiltrated the nodes in the lymphatic drain- tion or as a manifestation of some systemic dis-
age zone of an organ or tissue invaded by a eases. Occasionally they are the site of primary
malignant growth. RADIOTHERAPY or CHEMO- or metastatic malignant disease.
THERAPY may be given if laboratory tests show
that the type or extent of spread of the cancer Lymphocyte
cells merits this. A variety of white blood cell produced in the
LYMPHOID TISSUE and lymphatic glands (see
Lymphadenitis LYMPHATICS; GLAND) of the body. It contains a
Inflammation of lymphatic glands (see LYM- simple, rounded nucleus surrounded by proto-
PHATICS; GLAND). plasm generally described as non-granular. Two
varieties of lymphocyte are described, small and
Lymphadenoma large, and together they form over 20 per cent
Another name for Hodgkins disease. (See of the white cells of the blood. They play an
LYMPHOMA.) important part in the production of ANTI-
BODIES, and in the rejection of transplanted
Lymphadenopathy organs such as the heart (see TRANSPLANTA-
Medical description of swollen lymph glands TION). This they do in two different ways: what
(see GLAND). One cause is HIV infection (see are known as B-lymphocytes produce anti-
AIDS/HIV); another is spread of malignant cells bodies, while T-lymphocytes attack and destroy
from a tumour in the catchment area of lymph- antigens (see ANTIGEN) directly. The latter are
atic drainage. known as T-lymphocytes because they are pro-
duced by the THYMUS GLAND. Their numbers
Lymphangiectasis are increased in TUBERCULOSIS and certain
Lymphangiectasis means an abnormal dilata- other diseases. Such an increase is known as
tion of the lymph vessels, as in FILARIASIS. LYMPHOCYTOSIS.
 Lymphoma 425

Lymphocytosis Clinically the lymph glands are enlarged, rub-

An increase in the number of lymphocytes in bery but painless; usually those in the neck or
the blood (see LYMPHOCYTE) for example, in just above the CLAVICLE are affected. Spread is
response to viral infection or in chronic to adjacent lymph glands and in young
lymphocytic LEUKAEMIA. people a mass of enlarged glands may develop
in the MEDIASTINUM. The SPLEEN is affected
Lymphoedema in about one-third of patients with the dis-
Swelling of a part or organ due to obstruction order. Treatment is either with RADIO-
to the LYMPH vessels draining it. THERAPY, CHEMOTHERAPY or both, depend-
ing on when the disease is diagnosed and the
Lymphogranuloma Inguinale nature of the abnormal lymph cells. Cure
A venereal disease in which the chief character- rates are good, especially if the lymphoma is
istic is enlargement of glands in the groin the diagnosed early.
infecting agent being a virus.
Non-Hodgkins lymphoma (NHL) This
Lymphoid Tissue varies in its malignancy depending on the
Tissue involved in the formation of LYMPH, nature and activity of the abnormal lymph cells.
lymphocytes (see LYMPHOCYTE), and ANTI- The disease is hard to classify histologically, so
BODIES. It consists of the LYMPH NODES, THY- various classification systems have been evolved.
MUS GLAND, TONSILS and SPLEEN. High- and low-grade categories are recognised
according to the rate of proliferation of
Lymphokines abnormal lymph cells. No single causative fac-
Lymphokines are polypeptides that are pro- tor has been identified, although viral and bac-
duced by lymphocytes (see LYMPHOCYTE) as terial infections have been linked to NHL, and
part of their immune response to an ANTIGEN; genetic and immunological factors may be
their function is to communicate with other implicated. The incidence is higher than that of L
cells of the immune system (see IMMUNITY). Hodgkins disease, at 12 new cases per 100,000
Some lymphokines stimulate B-cells to differ- population a year, and the median age of diag-
entiate into antibody-producing plasma cells; nosis is 6570 years. Suppression of the
others stimulate T-lymphocytes to proliferate; immune system that ocurs in people with HIV
other lymphokines become interferons (see infection has been linked with a marked rise in
INTERFERON). the incidence of non-Hodgkins lymphoma and
Hodgkins disease.
Lymphoma Most patients have painless swelling of one
A malignant tumour of the LYMPH NODES div- or more groups of lymph nodes in the neck or
ided histologically and clinically into two types: groin, and the liver and spleen may enlarge. As
Hodgkins disease, and non-Hodgkins lymph- other organs can also be affected, patients may
oma. Hodgkins disease or lymphadenoma was present with a wide range of symptoms, includ-
named after Thomas Hodgkin (17981866), a ing fever, itching and weight loss. If NHL
Guys Hospital pathologist, who first described occurs in a single group of lymph nodes,
the condition. radiotherapy is the treatment of choice; more
extensive infiltration of glands will require
Hodgkins disease The incidence is chemotherapy and sometimes both types of
around four new cases per 100,000 population treatment will be necessary. If these treatments
annually, with slightly more men than women fail, BONE MARROW TRANSPLANT may be car-
contracting it. The first incidence peak is in age ried out. Prognosis is good for low-grade NHL
group 2035 and the second in age group 50 (75 per cent of patients survive five years or
70. The cause of Hodgkins is not known, more); in more severe types the survival rate is
although it is more common in patients from 4050 per cent for two years.
small families and well-educated backgrounds. Another variety of lymphoma is found in
The disease is three times more likely to occur children in Africa, sometimes called after
in people who have had glandular fever (see Burkitt, the Irish surgeon who first identified it.
MONONUCLEOSIS) but no link with the Burkitts lymphoma is a rapidly growing malig-
EPSTEIN BARR VIRUS has been established (see nant tumour occurring in varying sites, and the
Burkitts lymphoma, below) Epstein Barr virus has a role in its origin and
The disease is characterised histologically by growth. A non-African variety of Burkitts
the presence of large malignant lymphoid cells lymphoma is now also recognised. CYTOTOXIC
(Reed-Sternberg cells) in the lymph glands. drug therapy is effective.
 426 Lymphosarcoma

Lymphosarcoma dissolution of a blood clot, or the destruction of

A traditional term for non-Hodgkins lymph- CELLS as a result of damage to or rupture of the
oma (see LYMPHOMA). PLASMA membrane, thus allowing the cell con-
tents to escape.
Lysergic Acid Diethylamide
(LSD) Lysol
Lysergic acid diethylamide belongs to the ergot A brown, clear, oily fluid with antiseptic prop-
group of ALKALOIDS. It has various effects on erties, made from coal-tar and containing 50
the brain, notably analgesic and hallucinogenic, per cent CRESOL. When mixed with water it
thought to be due to its antagonism of 5- forms a clear soapy fluid.
hydroxytryptamine (5-HT). In small doses it
induces psychic states, in which the individual Lysol Poisoning
may become aware of repressed memories. For When LYSOL is swallowed it burns the mouth
this reason it may help in the treatment of and throat. Brown discoloration of the affected
certain anxiety states, if used under skilled tissues, accompanied by the characteristic smell
supervision. LSD rapidly induces TOLERANCE, of lysol on the breath, is typical.
however, and psychological DEPENDENCE
may occur, although not physical dependence. Treatment This is urgent. If the skin has
Serious side-effects include psychotic reactions, been contaminated with the lysol, it must be
with an increased risk of suicide. washed with water, and any lysol-contaminated
clothing must be taken off. Do not make the
Lysine victim vomit if he or she has swallowed a corro-
An essential amino acid (see AMINO ACIDS; sive substance such as lysol or phenol. Call an
INDISPENSABLE AMINO ACIDS), lysine was first ambulance and say what the victim has taken.
isolated in 1889 from casein, the principal pro- See APPENDIX 1: BASIC FIRST AID.
L tein of milk. Like other essential amino acids, it
ensures optimum growth in infants and bal- Lysozyme
anced nitrogen metabolism in adults. An ENZYME present in tears and egg white,
lysozyme catalyses the destruction of some bac-
Lysis teria by damaging their walls.
The gradual ending of a fever, and the opposite
of CRISIS, which signifies the sudden ending of a Lyssa
fever. It is also used to describe the process of Lyssa is another term for RABIES.
 and central nervous system. Free macrophages

M move between cells and, using their scavenger

properties, collect at infection sites to remove
foreign bodies, including bacteria. Fixed
macrophages are found in connective tissue.

Macropsia
Maceration Condition in which objects appear larger than
Maceration is the softening of a solid by soak- normal. It can be due to disease of the MACULA
ing in fluid. see also EYE.

Macr-/Macro- Macula
Prefix denoting large-sized cell for example, a A spot or area of tissue that is different from the
MACROPHAGE is a large PHAGOCYTE. surrounding tissue. An example is the macula
letea, the yellow spot in the retina of the EYE.
Macrocyte
Macrocyte is an unusually large red blood cell Macules
(see ERYTHROCYTES) especially characteristic Areas of small, flat or slightly raised skin dis-
of the blood in PERNICIOUS ANAEMIA. coloration which may occur in a wide range of
conditions such as many viral infections,
Macrocytosis eczema (DERMATITIS), PSORIASIS, SYPHILIS and
This condition is particularly associated with after burns (see BURNS AND SCALDS), as well as
PERNICIOUS ANAEMIA but can also be caused by in pregnancy.
a number of other things, such as alcohol, preg-
nancy, myxoedema (see THYROID GLAND, Maculopapular
DISEASES OF Hypothyroidism) and MYELO- A skin rash that is made up of macules (dis-
MATOSIS, and also by vitamin B12 deficiency: this coloration of the skin) and papules (raised
occurs sometimes in vegans (see VEGANISM) as abnormalities of the skin).
well as in patients with CROHNS DISEASE.
Madura Foot
Macroglossia Tropical infection of the foot by deeply invasive
An abnormally large TONGUE. fungi which cause chronic swelling and sup-
puration with multiple discharging sinuses.
Macrolides Antibiotics are of limited value and advanced
A group of ANTIBIOTICS. The original mac- disease may require amputation of the affected
rolide, ERYTHROMYCIN, was discovered in the foot.
early 1950s and used successfully as an alterna-
tive to PENICILLIN. The name macrolide Magnesium
derives from the molecular structure of this Magnesium is a light metallic element; it is one
group, three others of which are clarithromycin, of the essential mineral elements of the body,
azithromycin and spiramycin. Macrolides check without which the body cannot function prop-
PROTEIN synthesis in BACTERIA and the latest erly. The adult body contains around 25 grams
ones are, like erythromycin, active against sev- of magnesium, the greater part of which is in
eral bacterial species including gram-positive the bones. More than two-thirds of our daily
COCCI and rods. In addition, they act against supply comes from cereals and vegetables; as
Haemophilus influenzae. Clarithromycin is most other foods also contain useful amounts,
potent against Helicobacter pylori; azithromycin there is seldom any difficulty in maintaining an
is effective against infections caused by Legion- adequate amount in the body. Magnesium is
ella spp. (see LEGIONNAIRES DISEASE) and also an essential constituent of several vital
GONOCOCCI. Spiramycin is a restricted-use enzymes (see ENZYME). Deficiency leads to mus-
macrolide prescribed for pregnant patients with cular weakness and interferes with the efficient
TOXOPLASMOSIS. working of the heart. The salts of magnesium
used as drugs are the hydroxide of magnesium,
Macrophage the oxide of magnesium generally known as
A largePHAGOCYTE that forms part of the magnesia and the carbonate of magnesium,
RETICULO-ENDOTHELIAL SYSTEM. It is found in all of which have an antacid action; also the
many organs and tissues, including connective sulphate of magnesium known as Epsom salts,
tissue, bone marrow, lymph nodes, spleen, liver which acts as a purgative.
 428 Magnesium Trisilicate

Uses Compounds of magnesia are used to more sporozoites a stage in the life-cycle of
correct hyperacidity of the stomach and as a the parasite are injected into the human
laxative (see LAXATIVES). circulation; these are taken up by the hepato-
cytes (liver cells). Following division, mero-
Magnesium Trisilicate zoites (minute particles resulting from the
A white powder with mild antacid properties division) are liberated into the bloodstream
(see ANTACIDS) and a prolonged action, it is where they invade red blood cells. These in turn
used for treating peptic ulceration commonly divide, releasing further merozoites. As mero-
combined with quickly acting antacids. It has a zoites are periodically liberated into the blood-
mild laxative effect (see LAXATIVES). stream, they cause the characteristic fevers,
rigors, etc.
Magnetic Resonance Imaging Malaria occurs in many tropical and sub-
(MRI) tropical countries; P. falciparum is, however,
See MRI. confined very largely to Africa, Asia and South
America. Malaria is present in increasingly large
Malabsorption Syndrome areas; in addition, the parasites are developing
This term includes a multiplicity of diseases, all resistance to various preventative and treatment
of which are characterised by faulty absorption drugs. The disease constitutes a significant
from the INTESTINE of essential foodstuffs such problem for travellers, who must obtain sound
as fat, vitamins and mineral salts. Among the advice on chemoprophylaxis before embarking
conditions in this syndrome are COELIAC DIS- on tropical trips especially to a rural area
EASE, SPRUE, CYSTIC FIBROSIS and pancreatitis where intense transmission can occur. Trans-
(see PANCREAS, DISORDERS OF). Surgical mission has also been recorded at airports, and
removal of the small intestine also causes the following blood transfusion.
syndrome. Symptoms include ANAEMIA, diar- The World Health Organisation (WHO) has
rhoea, OEDEMA, vitamin deficiencies, weight listed malaria as one of Europes top ten infec-
loss and, in severe cases, MALNUTRITION. tious diseases. In 1992, 20,000 cases were
reported: this had risen to more than 200,000
M Malacia by the late 1990s. The resurgence of malaria has
Malacia is a term applied to softening of a part been worldwide, in part the result of the devel-
or tissue in disease: for example, OSTEO- opment of resistant strains of the disease, and in
MALACIA or softening of the bones. part because many countries have failed (or
been unable) to implement environmental
Malaise measures to eliminate mosquitoes. Nearly 40
A vague feeling of feverishness, listlessness and years ago the WHO forecast that by 1980 only
languor, malaise sometimes precedes the onset four million people would be affected world-
of serious acute diseases, but more commonly wide; now, at the beginning of the 21st century,
accompanies passing illnesses such as DYS- around 500 million people a year are contract-
PEPSIA, chills and colds. ing malaria with about 3,000 people a day
dying from the infection as many as 70 per
Malar cent of them children under the age of five,
Anything relating to the cheek. For example, according to WHO figures. The apparently
the malar (zygomatic) bone is also known as the steady advance of global warming means that
cheek bone, and a malar flush is reddening of countries with temperate climates may well
the cheeks. warm up sufficiently to enable malaria to
become established as an ENDEMIC disease. In
Malaria any case, the great increase in international air
A parasitic disease caused by four species of travel has exposed many more people to the risk
PLASMODIUM: P. falciparum, P. vivax, P. ovale, of malaria, and infected individuals may not
and P. malariae. Clinically, malaria is character- exhibit symptoms until they are back home.
ised by recurrent episodes of high fever, some- Doctors seeing a recent traveller with
times associated with RIGOR; enlargement of unexplained pyrexia and illness should consider
the SPLEEN is common. P. falciparum infection the possibility of malarial infection.
can also be associated with several serious Diagnosis is by demonstration of tropho-
often fatal complications (see below): zoites a stage in the parasites life-cycle that
although other species cause chronic disease, takes place in red blood cells in thick/thin
death is unusual. blood-films of peripheral blood. Serological
During a bite by the female mosquito, one or tests are of value in deciding whether an
 Maldescended Testis 429

individual has had a past infection, but are of skin barrier protection and vaporised insecti-
no value in acute disease. cides are helpful. Lotions, sprays or roll-on
applicators all containing diethyltoluamide
P. vivax and P. ovale infections cause less (DEET) are safe and work when put on the
severe disease than P. falciparum (see below), skin. Their effect, however, lasts only for a few
although overall there are many clinical similar- hours. Long sleeves and trousers should be
ities; acute complications are unusual, but worn after dark.
chronic ANAEMIA is often present. Primaquine Drug prophylaxis should be started at least a
is necessary to eliminate the exoerythrocytic week before travelling into countries where
cycle in the hepatocyte (liver cell). malaria is endemic (two or three weeks in the
case of mefloquine). Drug treatment should be
P. falciparum Complications of P. falci- continued for at least four weeks after leaving
parum infection include cerebral involvement endemic areas. Even if all recommended anti-
(see BRAIN Cerebrum), due to adhesion of malarial programmes are followed, it is possible
immature trophozoites on to the cerebral vascu- that malaria may occur any time up to three
lar endothelium; these lead to a high death rate months afterwards. Medical advice should be
when inadequately treated. Renal involvement sought if any illness develops. Chloroquine can
(frequently resulting from HAEMOGLOBINU- be used as a prophylactic drug where the risk of
RIA), PULMONARY OEDEMA, HYPOTENSION, resistant falciparum malaria is low; otherwise,
HYPOGLYCAEMIA, and complications in preg- mefloquine or proguanil hydrochloride should
nancy are also important. In complicated dis- be used. Travellers to malaria-infested areas
ease, HAEMODIALYSIS and exchange TRANSFU- should seek expert advice on appropriate
SION have been used. No adequate controlled prophylactic treatment well before departing.
trial using the latter regimen has been carried
out, however, and possible benefits must be Treatment Various chemoprophylactic
weighed against numerous potential side- regimes are widely used. Those commmonly
effects for instance, the introduction of a prescribed include: chloroquine + paludrine,
wide range of infections, overload of the circu- mefloquine, and Maloprim (trimethoprim +
latory system with infused fluids, and other dapsone); Fansidar (trimethoprim + sulpham- M
complications. ethoxazole) has been shown to have significant
side-effects, especially when used in conjunc-
P. malariae usually produces a chronic infec- tion with chloroquine, and is now rarely used.
tion, and chronic renal disease (nephrotic syn- No chemotherapeutic regimen is totally effect-
drome) is an occasional sequel, especially in ive, so other preventive measures are again
tropical Africa. being used. These include people avoiding
Gross SPLENOMEGALY (hyper-reactive mal- mosquito bites, covering exposed areas of the
arious splenomegaly, or tropical splenomegaly body between dusk and dawn, and using mos-
syndrome) can complicate all four human quito repellents.
Plasmodium spp. infections. The syndrome Chemotherapy was for many years domin-
responds to long-term malarial chemoprophy- ated by the synthetic agent chloroquine. How-
laxis. BURKITTS LYMPHOMA is found in geo- ever, with the widespread emergence of
graphical areas where malaria infection is chloroquine-resistance, quinine is again being
endemic; the EPSTEIN BARR VIRUS is aetiologic- widely used. It is given intravenously in severe
ally involved. infections; the oral route is used subsequently
and in minor cases. Other agents currently
Prophylaxis Malaria specialists in the United in use include mefloquine, halofantrine,
Kingdom have produced guidance for residents doxycycline, and the artemesinin alkaloids
travelling to endemic areas for short stays. Drug (qinghaosu).
choice takes account of: Researchers are working on vaccines against
risk of exposure to malaria; malaria.
extent of drug resistance;
efficacy of recommended drugs and their
side-effects;
Malathion
Organophosphorus insecticide which is a pre-
criteria relevant to the individual (e.g. age,
pregnancy, kidney or liver impairment).
ferred scabicide and pediculocide; applied
externally; resistance is rare.
Personal protection against being bitten by
mosquitoes is essential. Permethrin- Maldescended Testis
impregnated nets are an effective barrier, while See under TESTICLE, DISEASES OF.
 430 Malformation

Malformation Malleolus
See DEFORMITIES. Name of either of the two bony prominences at
the ANKLE.
Malignant
A term applied in several ways to serious dis- Mallet Finger
orders. A TUMOUR is called malignant when it Deformation of a finger due to sudden forced
grows rapidly, tending to infiltrate surrounding flexion of the terminal joint, leading to rupture
healthy tissues and to spread to distant parts of of the tendon. As a result the individual is
the body, leading eventually to death (see unable to extend the terminal part of the finger,
CANCER). The term is also applied to types of which remains bent forwards. The middle, ring
disease which are much more serious than the and little fingers are most commonly involved.
usual form for example, MALIGNANT HYPER- Treatment is by splinting the finger. The end
TENSION. Malignant pustule is another name result is satisfactory provided that the patient
for ANTHRAX. has sufficient patience.

Malignant Hyperpyrexia Mallet Toe

See MALIGNANT HYPERTHERMIA. The condition in which it is not possible to
extend the terminal part of the toe. It is usually
Malignant Hypertension due to muscular imbalance but may be caused
Malignant hypertension has nothing to do with by congenital absence of the extensor muscle. A
cancer; it derives its name from the fact that, if callosity (see CALLOSITIES) often forms on the
untreated, it runs a rapidly fatal course. (See toe, which may be painful. Should this be
HYPERTENSION.)
troublesome, treatment consists of removal of
the terminal phalanx.
Malignant Hyperthermia Malleus
This disorder is a rare complication of general The hammer-shaped lateral bone of the group
ANAESTHESIA caused, it is believed, by a com-
of three that form the sound-transmitting
M bination of an inhalation anaesthetic (usually ossicles in the middle ear. (See EAR.)
HALOTHANE) and a muscle-relaxant drug (usu-
ally succinycholine). A life-endangering rise in Malnutrition
temperature occurs, with muscular rigidity the The condition arising from an inadequate or
first sign. TACHYCARDIA, ACIDOSIS and SHOCK unbalanced DIET. The causes may be a lack of
usually ensue. About 1:20,000 patients having one or more essential nutrients, or inadequate
general anaesthesia suffer from this disorder, absorption from the intestinal tracts. A diet that
which progresses rapidly and is often fatal. Sur- is deficient in CARBOHYDRATE usually contains
gery and anaesthesia must be stopped immedi- inadequate PROTEIN, and this type of malnutri-
ately and appropriate corrective measures taken, tion occurs widely in Africa and Asia as a result
including the intravenous administration of of poverty, famine or war.
DANTROLENE. It is a dominantly inherited gen-
etic condition; therefore, when a case is identi- Maloprim
fied it is most important that relatives are A combination of PYRIMETHAMINE and DAP-
screened. SONE which is used for the prevention of MAL-
ARIA in limited circumstances. It has the advan-
Malignant Lymphoma tage of only needing to be taken once weekly. It
See LYMPHOMA. should not be taken by anyone hypersensitive to
sulphonamides, and should not be used for the
Malignant Melanoma treatment of an acute attack.
See MELANOMA.
Malpractice
Malingering An American term implying improper or
Malingering is a term applied to the feigning inadequate medical treatment that fails to
of illness. In the great majority of cases, a per- match the standards of skill and care reasonably
son who feigns illness has a certain amount of expected from a qualified health-care prac-
disability, but exaggerates the illness or dis- titioner usually a doctor or dentist. Litigation
comfort for some ulterior motive for against health professionals for malpractice has
example, to take time off work or to obtain been running at substantial levels in the USA
compensation. for some years. During the past decade the
 Mania 431

number of cases has been rising sharply in the to treat breast cancer; to enlarge small breasts;
United Kingdom, where the more usual term is or to reduce the size of overlarge breasts. The
clinical negligence. The increase is assumed to routine method for breast enlargement used to
be partly because of failings in the NHS, and be the insertion of silicone (see SILICONES)
partly because patients have more understand- implants under the skin; controversy about the
ing of health care, accompanied by higher long-term safety of silicone, however, has
expectations of treatment outcomes. restricted their use mainly to women needing
Patients concerned that they or their relatives reconstruction of their breasts after cancer sur-
might have been subject to negligence which gery. Side-effects have included hardening of
has caused harm should consult a solicitor breast tissue, leaking of implants and develop-
experienced in the field of clinical negligence. ment of scar tissue. (See also MASTECTOMY.)
www.avma.org.uk
Managed Health Care
Malpresentation This process aims to reduce the costs of
A situation during childbirth in which a baby is health care while maintaining its quality. The
not in the customary head-first position before concept originated in the United States but
delivery. The result is usually a complicated has attracted interest in the United Kingdom
labour in which a caesarean operation may be and Europe, where the spiralling costs of
necessary to effect the birth. (See PREGNANCY health care have been causing widespread
AND LABOUR.) concern. Managed care works through chan-
ging clinical practice, but it is not a discrete
Malta Fever entity: the American I. J. Iglehart has defined
See BRUCELLOSIS. it as a variety of methods of financing and
organising the delivery of comprehensive
Mammary Gland health care in which an attempt is made to
See BREASTS. control costs by controlling the provision of
services. Managed care has three facets:
Mammography health policy; how that policy is managed;
The special technique whereby X-rays are used and how individuals needing health care are M
to show the structure of the breast or any dealt with. The process and its applications
abnormalities in it (see BREASTS; BREASTS, DIS- are still evolving and it is likely that different
EASES OF). It is an effective way of distinguish- health-care systems will adapt it to suit their
ing benign from malignant tumours, and can own particular circumstances.
detect tumours that are not palpable. In a
multi-centre study in the USA, called the Mandelic Acid
Breast Cancer Detection Demonstration Pro- Also known as mandelamine, a non-toxic keto-
ject and involving nearly 300,000 women in acid used in the treatment of infections of the
the 4049 age group, 35 per cent of the urinary tract, especially those due to the
tumours found were detected by mammog- Escherichia coli and the Streptococcus faecalis or
raphy alone, 13 per cent by physical examin- Enterococcus. It is administered in doses of 3
ation, and 50 per cent by both methods com- grams several times daily. As it is only effective
bined. The optimum frequency of screening is in an acid urine, ammonium chloride must be
debatable: the American College of Radiolo- taken at the same time.
gists recommends a baseline mammogram at
the age of 40 years, with subsequent mammog- Mandible
raphy at one- to two-year intervals up to the age The bone of the lower JAW.
of 50; thereafter, annual mammography is
recommended. In the United Kingdom a less Manganese
intensive screening programme is in place, with A metal, oxides of which are found abundantly
women over 50 being screened every three in nature. Permanganate of potassium is a well-
years. As breast cancer is the commonest malig- known disinfectant. The body requires small
nancy in western women and is increasing in amounts of the metal for normal growth and
frequency, the importance of screening for this development. (See also TRACE ELEMENTS.)
form of cancer is obvious.
Mania
Mammoplasty A form of mental disorder characterised by
A surgical operation to reconstruct a breast (see great excitement. (See MENTAL ILLNESS.)
BREASTS) after part or all of it has been removed
 432 Manic Depression

Manic Depression MAOIs

Manic depression, or CYCLOTHYMIA, is a form See MONOAMINE OXIDASE INHIBITORS (MAOIS).
of MENTAL ILLNESS characterised by alternate
attacks of mania and depression. Marasmus
Progressive wasting, especially in young chil-
Manipulation dren, when there is no ascertainable cause. It is
The passive movement (frequently forceful) of generally associated with defective feeding. (See
bones, joints, or soft tissues, carried out by also ATROPHY; INFANT FEEDING.)
orthopaedic surgeons, physiotherapists (see
PHYSIOTHERAPY), osteopaths (see OSTEOPATHY) Marburg Disease
and chiropractors (see CHIROPRACTOR) as an This is also known as green monkey disease, or
important part of treatment often highly vervet monkey disease, because the first
effective. It may be used for three chief reasons: recorded human cases acquired their infection
correction of deformity (mainly the reduction from monkeys of this genus. It is a highly dan-
of fractures and dislocations, or to overcome gerous viral infection with a high mortality rate.
deformities such as congenital club-foot see The incubation period is 49 days. The onset is
TALIPES); treatment of joint stiffness (particu- sudden with marked nausea and severe head-
larly after an acute limb injury, or FROZEN ache; this is followed by rising temperature,
SHOULDER); and relief of chronic pain (particu- diarrhoea, and vomiting. Towards the end of
larly when due to chronic strain, notably of the the first week a rash appears which persists for a
spinal joints see PROLAPSED INTERVERTEBRAL week and is accompanied by internal bleeding.
DISC). Depending on the particular injury or In those who recover, convalescence is slow and
deformity being treated, and the estimated prolonged. Apart from laboratory infections
force required, manipulation may be used with acquired through working with vervet mon-
or without ANAESTHESIA. Careful clinical and keys, all the cases so far reported have occurred
radiological examination, together with other in Africa.
appropriate investigations, should always be
M carried out before starting treatment, to reduce March Fracture
the risk of harm, or disasters such as fractures or A curious condition in which a fracture occurs
the massive displacement of an intervertebral of the second (rarely, the third) metatarsal bone
disc. in the foot without any obvious cause. The
usual story is that a pain suddenly developed in
Mannitol the foot while walking or marching (hence the
An osmotic diuretic (see DIURETICS) given by a name), and that it has persisted ever since. The
slow intravenous infusion to reduce OEDEMA of only treatment needed is immobilisation of the
the BRAIN or raised intraocular pressure in foot and rest, and the fracture heals satisfactor-
GLAUCOMA. ily. (For more information on fractures, see
BONE, DISORDERS OF Bone fractures.)
Manometer
An instrument for measuring the pressure or March Haemoglobinuria
tension of liquids or gases. (See BLOOD A complication of walking and running over
PRESSURE.) long distances. It is due to damage to red blood
cells in the blood vessels of the soles of the feet.
Mantoux Test This results in HAEMOGLOBIN being released
A test for TUBERCULOSIS. It consists in injecting into the bloodstream, which is then voided in
into the superficial layers of the skin (i.e. intra- the URINE the condition known as HAEMO-
dermally) a very small quantity of old TUBER- GLOBINURIA. No treatment is required.
CULIN which contains a protein ANTIGEN to
TB. A positive reaction of the skin swelling Marfans Syndrome
and redness shows that the person so reacting An inherited disorder affecting about one per-
has been infected at some time in the past with son in 50,000 in which the CONNECTIVE TIS-
Mycobacterium tuberculosis. However, it does SUE is abnormal. The result is defects of the
not mean that such a person is suffering from heart valves, the arteries arising from the heart,
active tuberculosis. the skeleton and the eyes. The victims are
unusually tall and thin with a particular facial
Manubrium appearance (the US President Abraham Lincoln
The uppermost part of the STERNUM or was said to have Marfans) and deformities
breastbone. of the chest and spine. They have spider-like
 Mastectomy 433

fingers and toes and their joints and ligaments by trained practitioners. A complete list of
are weak. Orthopaedic intervention may help, members of the Chartered Society of Physio-
as will drugs to control the heart problems. As therapy can be obtained on application to the
affected individuals have a 50 per cent chance Secretary of the Society.
of passing on the disease to their children, they
should receive genetic counselling. Masseter
An important muscle of MASTICATION that
Marijuana extends from the zygomatic arch in the cheek to
Another term for CANNABIS, hemp, or hashish. the mandible or jawbone. It acts by closing the
(See also DEPENDENCE.) jaw.

Marriage Guidance Mass Hysteria

See RELATE MARRIAGE GUIDANCE. See HYSTERIA.

Marrow Mass Miniature Radiography

See BONE MARROW. A method of obtaining X-ray photographs of
the chests of large numbers of people. It has
Marsh Fever been used on a large scale as a means of screen-
See MALARIA. ing the population for pulmonary TUBERCU-
LOSIS. It is no longer used in the United
Mask Kingdom.
A device that covers the nose and mouth to
enable inhalation anaesthetics (see ANAES- Mastalgia
THESIA) or other gases such as oxygen to be The term applied to pain in the breast (see
administered. It is also a covering for the nose BREASTS; BREASTS, DISEASES OF).
and mouth to ensure that antiseptic conditions
are maintained during surgery, when dressing a Mast Cells
wound or nursing a patient in conditions of Round or oval cells found predominantly in
isolation. The term is also applied to the expres- the loose CONNECTIVE TISSUE. They contain M
sionless appearance that occurs in certain HISTAMINE and HEPARIN, and carry immuno-
disorders for example, in PARKINSONISM. globulin E, the antibody which plays a
predominant part in allergic reactions (see
Masochism ANTIBODIES; ALLERGY). Although known to
A condition in which a person gets pleasure play a part in inflammatory reactions, allergy,
from physical or emotional pain inflicted by and hypersensitivity, their precise function in
others or themselves. The term is often used in health and disease is still not quite clear.
the context of achieving sexual excitement
through inflicted pain. Masochism may be a Mastectomy
conscious or subconscious activity. A surgical operation to remove part or all of the
breast (see BREASTS). It is usually done to treat
Massage cancer, when it is commonly followed by
A method of treatment in which the operator CHEMOTHERAPY or RADIOTHERAPY (see
uses his or her hands, or occasionally other BREASTS, DISEASES OF). There are four types of
appliances, to rub the skin and deeper tissues of mastectomy: lumpectomy, quandrantectomy,
the person under treatment. It is often com- subcutaneous mastectomy and total mast-
bined with (a) passive movements, in which the ectomy. The choice of operation depends upon
masseur/masseuse moves the limbs in various several factors, including the site and nature of
ways, the person treated making no effort; or the tumour and the patients age and health.
(b) active movements, which are performed Traditionally, radical mastectomy was used to
with the combined assistance of masseur/mas- treat breast cancer; in the past three decades,
seuse and patient. Massage is also often com- however, surgeons and oncologists have become
bined with baths and gymnastics in order to more selective in their treatment of the disease,
strengthen various muscles. It helps to improve bringing the patient into the decision-making
circulation, prevent adhesions in injured tis- on the best course of action. Lumpectomy is
sues, relax muscular spasm, improve muscle done where there is a discrete lump less than 2
tone and reduce any oedema. (See also CARDIAC cm in diameter with no evidence of glandular
MASSAGE.) spread. A small lump (25 cm) with limited
Massage for medical conditions is best done spread to the glands may be removed by
 434 Mastication

quadrantectomy or subcutaneous mastectomy when the middle ear is diseased. (See under EAR,
(which preserves the nipple and much of the DISEASES OF.)
skin, so producing a better cosmetic effect).
Lumps bigger than 5 cm and fixed to the under- Masturbation
lying tissues require total mastectomy in which The production of an ORGASM by self-
the breast tissue, skin and some fat are dissected manipulation of the PENIS or CLITORIS.
down to the chest muscles and removed. In
addition, the tail of the breast tissue and Mat Burn
regional lymph glands are removed. In all types A combination of a burn and an abrasion which
of mastectomy, surgeons endeavour to produce occurs in wrestlers when the skin over the bony
as good a cosmetic result as possible, subject to points is rubbed against the unyielding canvas
the adequate removal of suspect tissue and mat.
glands.
Breast reconstructive surgery (MAM- Materia Medica
MOPLASTY) may be done at the same time as the The branch of medical study which deals with
mastectomy the preferred option or, if that the sources, preparations and uses of drugs. (See
is not feasible, at a later date. Where the whole MEDICINES.)
breast has been excised, some form of artificial
breast (prosthesis) will be provided. This may Maxilla
be an external prosthesis fitted into a specially The name applied to the upper jawbones,
made brassiere, or an internal implant per- which bear the teeth.
haps a silicone bag, though there has been
controversy over the safety of this device. ME
Reconstructive techniques involving the trans- See MYALGIC ENCEPHALOMYELITIS (ME).
fer of skin and muscle from nearby areas are also
being developed. Post-operatively, patients can Mean
obtain advice from Breast Cancer Care. A statistical term meaning the value obtained
when you add up the total of a set of observa-
M Mastication tions and divide the result by the number of
The act whereby, as a result of movements of observations. It can give a false impression if
the lower jaw, lips, tongue, and cheek, food is there are a few outliers individual results well
reduced to a condition in which it is ready to be beyond the range of the remainder.
acted on by the gastric juices in the process of
DIGESTION. Adequate mastication before swal- Measles
lowing is an essential part of the digestive Measles, formerly known as morbilli, is an
process. acute infectious disease occurring mostly in
children and caused by an RNA paramyxovirus.
Mastitis
The term applied to inflammation of the breast Epidemiology There has been a dramatic
(see BREASTS, DISEASES OF). fall in the number of sufferers from 1986, when
more than 80,000 cases were reported. This is
Mastocytosis due to the introduction in 1988 of the measles,
A rare condition in which the primary mumps and rubella vaccine (MMR VACCINE see
abnormality is of MAST CELLS a type of cell also IMMUNISATION); 1990, when the propor-
responsible for the storage and release of tion of children immunised reached 90 per
agents such as HISTAMINE, important in aller- cent, was the first year in which no deaths from
gic states. Patients may present with an urti- measles were reported. Even so, fears of side-
carial rash (urticaria pigmentosa) but may have effects of the vaccine against measles includ-
symptoms referable to any part of the body, ing scientifically unproven and discredited
related to collections of active mast cells in claims of a link with AUTISM mean that some
these areas. children in the UK are not being immunised,
and since 2002 local outbreaks of measles have
Mastoid Process been reported in a few areas of the UK. Side-
The large process of the temporal bone of the effects are, however, rare and the government is
SKULL which can be felt immediately behind campaigning to raise the rate of immunisation,
the ear. It contains numerous cavities, one of with GPs being set targets for their practices.
which the mastoid antrum communicates There are few diseases as infectious as mea-
with the middle ear, and is liable to suppurate sles, and its rapid spread in epidemics is no
 Median 435

doubt due to the fact that this viral infection is Meckels Diverticulum
most potent in the earlier stages. Hence the dif- A hollow pouch sometimes found attached to
ficulty of timely isolation, and the readiness the small INTESTINE. It is placed on the small
with which the disease is spread, which is intestine about 90120 cm (34 feet) from its
mostly by infected droplets. In developing junction with the large intestine, is several
countries measles results in the death of more centimetres long, and ends blindly. It is lined
than a million children annually. with cells similar to those which line the stom-
ach, and so may produce acid. This leads to
Symptoms The incubation period, during occasional illness Meckels diverticulitis with
which the child is well, lasts 721 days. Initial ulceration, which causes abdominal pain and
symptoms are CATARRH, conjunctivitis (see EYE, fever (sometimes referred to as left-sided
DISORDERS OF), fever and a feeling of wretch- appendicitis). Perforation may result in PERI-
edness. Then Koplik spots a classic sign of TONITIS and, rarely, may be the lead point of an
measles appear on the roof of the mouth and INTUSSUSCEPTION.
lining of the cheeks. The macular body rash,
typical of measles, appears 35 days later. Meconium
Common complications include otitis media The brown, semi-fluid material which collects
(see under EAR, DISEASES OF) and PNEUMONIA. in the bowels of a FETUS before birth, and
Measles ENCEPHALITIS can cause permanent which should be discharged either at the time of
brain damage. A rare event is a gradual dement- birth or shortly afterwards. It consists partly of
ing disease (see DEMENTIA) called subacute BILE secreted by the liver before birth; partly of
sclerosing panenecephalitis (SSPE). debris from the mucous membrane of the
intestines.
Treatment Isolation of the patient and
treatment of any secondary bacterial infection, Media
such as pneumonia or otitis, with antibiotics. The middle layer of an organ or tissue, but
Children usually run a high temperature which more usually applied to the wall of an artery or
can be relieved with cool sponging and anti- vein, where the media comprises layers of elastic M
pyretic drugs. Calamine lotion may alleviate and smooth muscle fibres.
any itching.
Medial
Measures Near the middle of tissue, organ or body.
See APPENDIX 6: MEASUREMENTS IN MEDICINE.
Medial Tibial Syndrome
Meat The term applied by athletes to a condition
See PROTEIN. characterised by pain over the inner border of
the shin, which occurs in most runners and
Meatus sometimes in joggers. The syndrome, also
A term applied to any passage or opening: for known as shin splints, is due to muscular swell-
example, external auditory meatus the passage ing resulting in inadequate blood supply in the
from the surface to the drum of the EAR. muscle: hence the pain. The disorder may be
the result of compartment syndrome (build-up
Mebendazole of pressure in the muscles), TENDINITIS, muscle
An anthelmintic drug (see ANTHELMINTICS) or bone inflammation, or damage to the
used to treat threadworms (see ENTEROBIASIS). muscle. It usually disappears within a few
It is the drug of choice, except for in children weeks, responding to rest and PHYSIOTHERAPY,
aged two years or younger. A single dose is usu- with or without injections. In some cases, how-
ally effective, but reinfection is common and a ever, it becomes chronic and so severe that it
second treatment may be given after three occurs even at rest. If the cause is the compart-
weeks. ment syndrome, relief is usually obtained by a
simple operation to relieve the pressure in the
Mebeverine affected muscles.
A direct relaxant of the smooth muscle in the
INTESTINE, it may relieve pain in patients Median
with IRRITABLE BOWEL SYNDROME (IBS) or A statistical term which is the central value of a
DIVERTICULAR DISEASE. Adverse effects are set of values placed in order of size. The median
rare. divides the set into two halves.
 436 Mediastinum

Mediastinum required to develop education and training for

Mediastinum is the space in the chest which lies students and learners in all aspects of medical
between the two lungs. It contains the heart health care. Studies for undergraduate students,
and great vessels, the gullet, the lower part of postgraduate students and individual health-
the windpipe, the thoracic duct and the phrenic care practitioners, from the initial stages to the
nerves, as well as numerous structures of less ongoing development of a career in medicine or
importance. associated health fields, are also included in
medical education. The word pedagogy is
Medicaid sometimes applied to this process.
A joint state and federal health insurance A range of research investigations has
scheme in the United States that provides cover developed within medical education. These
for poorer people in the population. apply to course monitoring, audit, development
and validation, assessment methodologies and
Medical Audit the application of educationally appropriate
A systematic review of the procedures involved principles at undergraduate and postgraduate
in the diagnosis, care and treatment of patients. levels. Research is undertaken by medical edu-
Such a review includes the input of associated cationalists whose backgrounds include teach-
resources for example, social-services care and ing, social sciences and medicine and related
funding and an assessment of the outcome health-care specialties, and who will hold a
and quality of life for the patient(s). If the medical or general educational diploma, degree
review is undertaken by health-care profes- or other appropriate postgraduate qualification.
sionals, the process is called CLINICAL AUDIT. Development and validation for all courses
are an important part of continuing accredit-
Medical Defence Organisations ation processes. The relatively conservative
These are UK bodies that provide doctors with courses at both undergraduate and postgradu-
advice and, where appropriate, financial sup- ate levels, including diplomas and postgraduate
port in defending claims for medical negligence qualifications awarded by the specialist medical
in their clinical practice. They also advise doc- royal colleges (responsible for standards of spe-
M tors on all legal aspects of their work, including cialist education) and universities, have under-
patients complaints, and provide representa- gone a range of reassessment and redefinition
tion for members called to account by the driven by the changing needs of the individual
GENERAL MEDICAL COUNCIL (GMC) or other practitioner in the last decade. The stimuli to
regulatory body. The sharp rise in claims for change aspects of medical training have come
medical negligence in the NHS in the 1980s from the government through the former Chief
persuaded the UK Health Departments to Medical Officer, Sir Kenneth Calman, and the
introduce a risk-pooling system called the Clin- introduction of new approaches to specialist
ical Negligence Scheme for Trusts, and the training (the Calman programme), from the
defence societies liaise with this scheme when GENERAL MEDICAL COUNCIL (GMC) and its
advising their doctor members on responding document Tomorrows Doctors, as well as from
to claims of negligence (see MEDICAL LITIGA- the profession itself through the activities of the
TION; MEDICAL NEGLIGENCE). British Medical Association and the medical
royal colleges. The evolving expectations of the
Medical Devices Agency public in their perception of the requirements
An executive agency of the Department of of a doctor, and changes in education of other
Health in the UK. Set up in 1994, it is respon- groups of health professionals, have also led to
sible for regulating and advising on the sale or pressures for changes.
use of any product, other than a medicine, used Consequently, many new departments and
in the health-care environment for the diag- units devoted to medical education within uni-
nosis, prevention, monitoring or treatment of versity medical schools, royal colleges and
illness or disease. Equipment ranges from elsewhere within higher education have been
pacemakers (see CARDIAC PACEMAKER) to pros- established. These developments have built
theses (see PROSTHESIS), and from syringes to upon practice developed elsewhere in the
magnetic resonance imaging (see (MRI). world, particularly in North America, Australia
and some European countries. Undergraduate
Medical Education education has seen application of new edu-
This term is used to define the process of learn- cational methods, including Problem-Based
ing and knowledge-acquisition in the study of Learning (PBL) in Liverpool, Glasgow and
medicine. It also encompasses the expertise Manchester; clinical and communications skills
 Medical Litigation 437

teaching; early patient contact; and the exten- rate of about 810 per cent. This loss may in
sive adoption of Internet (World Wide Web) part be due to the changes in university-
support and Computer-Aided Learning (CAL). funding arrangements. Students now pay all or
In postgraduate education driven by Euro- part of their tuition fees, and this can result in
pean directives and practices, changes in spe- medical graduates owing several thousand
cialist training and the needs of community pounds when they qualify at the end of their
medicine new courses have developed around five-year basic qualification course. Doctors
the membership and fellowship examinations wishing to specialise need to do up to five
for the royal colleges. Examples of these changes years (sometimes more) of salaried hands-on
driven by medical education expertise include training in house or registrar (intern) posts.
the STEP course for the Royal College of Sur- Though it may be a commonly held belief
geons of England, and distance-learning courses that most students enter medicine for humani-
for diplomas in primary care and rheumatology, tarian reasons rather than for the financial
as well as examples of good practice as adopted rewards of a successful medical career, in
by the Royal College of General Practitioners. developed nations the prospect of status and
Continuing Professional Development rewards is probably one incentive. However, the
(CPD) and Continuing Medical Education cost to students of medical education along
(CME) are also important aspects of medical with the widespread publicity in Britain about
education now being developed in the United an under-resourced, seriously overstretched
Kingdom, and are evolving to meet the needs of health service, with staff working long hours
individuals at all stages of their careers. and dealing with a rising number of disgruntled
Bodies closely involved in medical edu- patients, may be affecting recruitment, since
cational developments and their review include the number of applicants for medical school has
the General Medical Council, SCOPME (the dropped in the past year or so. Although there is
Standing Committee on Postgraduate Medical still competition for places, planners need to
Education), all the medical royal colleges and bear this falling trend in mind.
medical schools, and the British Medical Another factor to be considered for the
Association through its Board of Medical Edu- future is the nature of the medical curriculum.
cation. The National Health Service (NHS) is In Britain and western Europe, the age struc- M
also involved in education and is a key to facili- ture of a probably declining population will
tation of CPD/CME as the major employer of become top-heavy with senior citizens. In the
doctors within the United Kingdom. financial interests of the countries affected, and
Several learned societies embrace medical in the personal interests of an ageing popula-
education at all levels. These include ASME tion, it would seem sensible to raise the profile
(the Association for the Study of Medical Edu- of preventive medicine traditionally rather a
cation), MADEN (the Medical and Dental Cinderella subject in medical education, thus
Education Network) and AMEE (the Associ- enabling people to live healthier as well as
ation for Medical Education in Europe). Spe- longer lives. While learning about treatments is
cialist journals are devoted to research reports essential, the increasing specialisation and sub-
relating to medical educational developments specialisation of medicine in order to provide
(e.g. Academic Medicine, Health Care Education, expensive, high-technology care to a popula-
Medical Education). The more general medical tion, many of whom are suffering from pre-
journals (e.g. British Medical Journal, New Eng- ventable illnesses originating in part from
land Journal of Medicine, The Lancet, Annals of self-indulgent lifestyles, seems insupportable
the Royal College of Surgeons) also carry articles economically, unsatisfactory for patients await-
on educational matters. Finally, the World ing treatment, and not necessarily profession-
Wide Web (WWW) is a valuable source of ally fulfilling for health-care staff. To change the
information relating to courses and course mix of medical education would be a difficult
development and other aspects of modern med- long-term task but should be worthwhile for
ical education. providers and recipients of medical care.
The UK government, which controls the
number of students entering medical training, Medical Informatics
has recently increased the quota to take account See INFORMATION TECHNOLOGY IN MEDICINE.
of increasing demands for trained staff from
the NHS. More than 5,700 students 3,300 Medical Litigation
women and 2,400 men are now entering UK Legal action taken by an individual or group of
medical schools annually with nearly 28,600 at individuals, usually patients, against hospitals,
medical school in any one year, and an attrition health-service providers or health professionals
 438 Medical Negligence

in respect of alleged inadequacies in the provi- ities of hospitals and universities. There are sev-
sion of health care. eral medical charities and foundations for
In the hospital service, claims for clinical neg- example, the Imperial Cancer Research Fund,
ligence have risen enormously since the 1970s. the British Heart Foundation, the Nuffield
In 1975 the NHS spent about 1m a year on Laboratories and the Wellcome Trust which
legal claims; by 2004 the NHS faced over 2 fund and foster medical research.
billion in outstanding claims. In 1995 a risk-
pooling Clinical Negligence Scheme for Trusts Medicare
(CNST) was set up in England, and is adminis- A health insurance scheme in the United States,
tered by the NHS Litigation Authority. NHS managed by the federal government, that pro-
trusts are expected to follow a set of risk- vides cover for Americans over the age of 65
management standards, the first being that each who have certain disabilities.
trust should have a written risk-management
strategy with an explicit commitment to man- Medicated
aging clinical risk (see RISK MANAGEMENT). Description of a substance that contains a
medicinal drug, commonly applied to items
Medical Negligence such as sweets and soaps.
Under the strict legal definition, negligence
must involve proving a clearly established duty Medicine
of care which has been breached in a way that (1) The skills and science used by trained prac-
has resulted in injury or harm to the recipient of titioners to prevent, diagnose, treat and research
care. There does not need to be any malicious disease and its related factors.
intention. Whether or not a particular injury (2) A drug used to treat an individual with an
can be attributed to medical negligence, or illness or injury (see MEDICINES).
must simply be accepted as a reasonable risk of (3) The diagnosis and treatment of those dis-
the particular treatment, depends upon an eases not normally requiring surgical
assessment of whether the doctor has fallen intervention.
below the standard expected of practitioners in
M the particular specialty. A defence to such a Defensive medicine Diagnostic or treat-
claim is that a respected body of practitioners ment procedures undertaken by practitioners in
would have acted in the same way (even though which they aim to reduce the likelihood of legal
the majority might not) and in doing so would action by patients. This may result in requests
have acted logically. for investigations that, arguably, are to provide
legal cover for the doctor rather than more cer-
Medical Oncology tain clinical diagnosis for the patient.
See ONCOLOGY.
Medicine of Ageing
Medical Record Diseases developing during a persons lifetime
The information recorded and kept on paper may be the result of his or her lifestyle,
or electronically by health professionals about environment, genetic factors and natural AGE-
an individuals illness(es). The information is ING factors.
normally confidential to those responsible for
caring for the patient and to the patient, if he Lifestyle While this may change as people
or she should wish to see it. (See grow older for instance, physical activity is
CONFIDENTIALITY.) commonly reduced some lifestyle factors are
unchanged: for example, cigarette smoking,
Medical Research Council commonly started in adolescence, may be con-
A statutory body in the United Kingdom that tinued as an adult, resulting in smokers cough
promotes the balanced development of medical and eventually chronic BRONCHITIS and
and related biological research and aims to EMPHYSEMA; widespread ATHEROSCLEROSIS
advance knowledge that will lead to improved causing heart attacks and STROKE; osteoporosis
health care. It employs its own research staff in (see BONE, DISORDERS OF) producing bony frac-
more than 40 research establishments. These tures; and cancer affecting the lungs and
include the National Institute for Medical bladder.
Research, the Laboratory of Molecular Biology,
and the Clinical Sciences Centre. Grants are Genetic factors can cause sickle cell disease
provided so that individual scientists can do (see ANAEMIA), HUNTINGTONS CHOREA and
research which complements the research activ- polycystic disease of the kidney.
 Medicines 439

Ageing process This is associated with the 80s, there seems to be a reasonable case for
MENOPAUSE in women and, in both sexes, with training staff in the type of care these indi-
a reduction in the bodys tissue elasticity and viduals need and to facilitate research into ill-
often a deterioration in mental and physical ness at this stage of life.
capabilities. When compared with illnesses
described in much younger people, similar ill- Medicines
nesses in old age present in an atypical manner Medicines are drugs made stable, palatable and
for example, confusion and changed acceptable for administration. In Britain, the
behaviour due to otherwise asymptomatic heart Medicines Act 1968 controls the making,
failure, causing a reduced supply of oxygen to advertising and selling of substances used for
the brain. Social adversity in old age may result medicinal purposes, which means diagnosing,
from the combined effects of reduced body preventing or treating disease, or altering a
reserve, atypical presentation of illness, multiple function of the body. Permission to market a
disorders and POLYPHARMACY. medicine has to be obtained from the govern-
ment through the MEDICINES CONTROL
Age-related change in the presenta- AGENCY, or from the European Commission
tion of illnesses This was first recognised through the European Medicines Evaluation
by the specialty of geriatric medicine (also Agency. It takes the form of a Marketing
called the medicine of ageing) which is con- Authorisation (formerly called a Product
cerned with the medical and social manage- Licence), and the uses to which the medicine
ment of advanced age. The aim is to assess, treat can be put are laid out in the Summary of
and rehabilitate such patients. The number of Product Characteristics (which used to be called
institutional beds has been steadily cut, while the Product Data Sheet).
availability of day-treatment centres and respite There are three main categories of licensed
facilities has been boosted although still medicinal product. Drugs in small quantities
inadequate to cope with the growing number of can, if they are perceived to be safe, be licensed
people over 65. for general sale (GSL general sales list), and
These developments, along with day social may then be sold in any retail shop. P
centres, provide relatives and carers with a break (pharmacy-only) medicines can be sold from a M
from the often demanding task of looking after registered pharmacy by or under the supervi-
the frail or ill elderly. As the proportion of eld- sion of a pharmacist (see PHARMACISTS); no pre-
erly people in the population rises, along with scription is needed. P and GSL medicines are
the cost of hospital inpatient care, close co- together known as OTCs that is, over-the-
operation between hospitals, COMMUNITY counter medicines. POM (prescription-only
CARE services and primary care trusts (see under medicines) can only be obtained from a regis-
GENERAL PRACTITIONER (GP)) becomes increas- tered pharmacy on the prescription of a doctor
ingly important if senior citizens are not to suf- or dentist. As more information is gathered on
fer from the consequences of the tight operating the safety of drugs, and more emphasis put on
budgets of the various medical and social individual responsibility for health, there is a
agencies with responsibilities for the care of the trend towards allowing drugs that were once
elderly. Private or voluntary nursing and resi- POM to be more widely available as P medi-
dential homes have expanded in the past 15 cines. Examples include HYDROCORTISONE 1
years and now care for many elderly people who per cent cream for skin rashes, CIMETIDINE for
previously would have been occupying NHS indigestion, and ACICLOVIR for cold sores. Care
facilities. This trend has been accelerated by a is needed to avoid taking a P medicine that
tightening of the benefit rules for funding such might alter the actions of another medicine
care. Local authorities are now responsible for taken with it, or that might be unsuitable for
assessing the needs of elderly people in the other reasons. Patients should read the patient-
community and deciding whether they are information leaflet, and seek the pharmacists
eligible for financial support (in full or in part) advice if they have any doubt about the informa-
for nursing-home care. tion. They should tell their pharmacist or doctor
With a substantial proportion of hospital if the medicine results in any unexpected effects.
inpatients in the United Kingdom being over Potentially dangerous drugs are preparations
60, it is sometimes argued that all health profes- referred to under the Misuse of Drugs Act 1971
sionals should be skilled in the care of the eld- and subsequent regulations approved in 1985.
erly; thus the need for doctors and nurses Described as CONTROLLED DRUGS, these
trained in the specialty of geriatrics is diminish- include such preparations as COCAINE, MOR-
ing. Even so, as more people are reaching their PHINE, DIAMORPHINE, LSD (see LYSERGIC ACID
 440 Medicines

DIETHYLAMIDE (LSD)), PETHIDINE HYDRO- Injection remains an important route of

CHLORIDE, AMPHETAMINES, BARBITURATES and administering drugs both locally (for example,
most BENZODIAZEPINES. into joints or into the eyeball), and into the
bloodstream. For this latter purpose, drugs can
Naming of drugs A European Community be given under the skin that is, subcutane-
Directive (92/27/EEC) requires the use of the ously (s.c. also called hypodermic injection);
Recommended International Non-proprietary into muscle intramuscularly (i.m.); or into a
Name (rINN) for medicinal substances. For vein intravenously (i.v.). Oily or crystalline
most of these the British Approved Name preparations of drugs injected subcutaneously
(BAN) and rINN were identical; where the two form a depot from which they are absorbed
were different, the BAN has been modified in only slowly into the blood. The action of drugs
line with the rINN. Doctors and other author- such as TESTOSTERONE and INSULIN can be pro-
ised subscribers are advised to write titles of longed by using such preparations, which also
drugs and preparations in full because unofficial allow contraceptive implants that work for
abbreviations may be misinterpreted. Where a some months (see CONTRACEPTION).
drug or preparation has a non-proprietary (gen-
eric) title, this should be used in prescribing Safe disposal of unwanted medicines
unless there is a genuine problem over the bio- Unwanted medicines are a form of con-
availability properties of a proprietary drug and trolled waste under the Environmental Protec-
its generic equivalent. tion Act 1990 and must be disposed of in an
Where proprietary commercially registered appropriate way. The best thing is to take any
names exist, they may in general be used only extra or unwanted medicines to a registered
for products supplied by the trademark owners. pharmacy. Syringes and needles (used by dia-
Countries outside the European Union have betic patients, for example) pose problems:
their own regulations for the naming of devices exist to cut off and retain the needle,
medicines. and some local authorities in the United King-
dom arrange for collection and safe disposal.
Methods of administration The ways in There are also local needle exchange schemes
M which drugs are given are increasingly ingeni- for intravenous drug abusers.
ous. Most are still given by mouth; some oral
preparations (slow release or controlled Safe use of medicines All medicines can
release preparations) are designed to release have unwanted effects (side-effects or, more
their contents slowly into the gut, to maintain strictly, adverse effects) that are unpleasant and
the action of the drug. sometimes harmful. It is best not to take any
Buccal preparations are allowed to dissolve in medicine, prescribed or otherwise, unless there
the mouth, and sublingual ones are dissolved is a clear reason for doing so; the possible
under the tongue. The other end of the gastro- adverse effects of treatment, and the risk of their
intestinal tract can also absorb drugs: supposi- occurring, have to be set against any likely
tories inserted in the rectum can be used for benefit. Remember too that one treatment can
their local actions for example, as laxatives affect another already being taken. Many
or to allow absorption when taking the drug by adverse events depend upon the recommended
mouth is difficult or impossible for example, dose being exceeded. Some people for
during a convulsion, or when vomiting. example, those with allergies (see ALLERGY) to a
Small amounts of drug can be absorbed particular group of drugs, or those with kidney
through the intact skin, and for very potent or liver disease are more likely to suffer
drugs like OESTROGENS (female sex hormones) adverse effects than otherwise healthy people.
or the anti-anginal drug GLYCERYL TRINITRATE, When an individual begins a course of
a drug-releasing patch can be used. Drugs can treatment, he or she should take it as instructed.
be inhaled into the lungs as a fine powder to With ANTIBIOTICS treatments especially, it is
treat or prevent ASTHMA attacks. They can also important to take the whole course of tablets
be dispersed (nebulised) as a fine mist which prescribed, because brief exposure of bacteria to
can be administered with compressed air or an antibiotic can make them resistant to treat-
oxygen. Spraying a drug into the nostril, so that ment. Most drugs can be stopped at once, but
it can be absorbed through the lining of the some treatments can cause unpleasant, and
nose into the bloodstream, can avoid destruc- occasionally dangerous, symptoms if stopped
tion of the drug in the stomach. This route is abruptly. Sleeping tablets, anti-EPILEPSY treat-
used for a small number of drugs like anti- ment, and medicines used to treat ANGINA PEC-
diuretic hormone (see VASOPRESSIN). TORIS are among the agents which can cause
 Meiosis 441

such withdrawal symptoms. CORTICO- Medulla Oblongata

STEROIDS are a particularly important group of The hindmost part of the BRAIN, continuing
medicines in this respect, because prolonged into the SPINAL CORD. In it are situated several
courses of treatment with high doses can sup- of the nerve centres which are most essential to
press the ability of the body to respond to severe life, such as those governing breathing, the
stresses (such as surgical operations) for many action of the heart and swallowing.
months or even years.
Mefenamic Acid
Medicines Commission One of the NON-STEROIDAL ANTI-
A government-appointed expert advisory body INFLAMMATORY DRUGS (NSAIDS) that is an
on the use of MEDICINES in the UK. analgesic (see ANALGESICS) for mild to moderate
pain in RHEUMATOID ARTHRITIS, OSTEO-
Medicines Control Agency ARTHRITIS and other musculoskeletal disorders.
An executive agency of the Department of Also used for DYSMENNORRHOEA and MENOR-
Health with the prime function of safeguard- RHAGIA. It must be used with care as it has
ing the public health. It ensures that branded several side-effects, in particular diarrhoea and
and non-branded MEDICINES on the UK mar- occasional haemolytic ANAEMIA. It must not be
ket meet appropriate standards of safety, qual- used in patients with INFLAMMATORY BOWEL
ity and efficacy. The agency applies the strict DISEASE (IBD).
standards set by the UK Medicines Act
(1968) and relevant European Community Megacolon
legislation. A greatly enlarged colon that may be present at
birth or develop later. It can occur in all age
Medicolegal groups and the condition is typified by severe
A term that relates to the practice of medicine chronic constipation. Megacolon is caused by
and law (see FORENSIC MEDICINE; MEDICAL obstruction of the colon which may be due to
LITIGATION; MEDICAL NEGLIGENCE). faulty innervation, or to psychological factors.
Other causes are HIRSCHSPRUNGS DISEASE or
Medlars ULCERATIVE COLITIS. In old people the persist-
M
Medical Literature Analysis and Retrieval Sys- ent use of powerful laxative drugs may cause the
tem a computerised index system produced condition.
by the US National Library of Medicine.
Megalomania
Medline A delusion of grandeur or an insane belief in a
A computer-based telephone line linkage to persons own extreme greatness, goodness, or
MEDLARS for rapid transmission of medical power.
information held by that library. Information
can be accessed worldwide. Information is also Mega-/Megalo-
available via the web. Prefixes denoting largeness.

Medroxyprogesterone Meibomian Glands

A PROGESTERONE (female sex hormone) Numerous glands within the tarsal plates of the
preparation which is given intramuscularly in eyelids. Their secretions form part of the tears.
long-acting form as a PROGESTOGEN-only con- (See EYE.)
traception; however, it should be given only
with counselling and full details of its action. Meiosis
The drug is also used as second- or third-line Meiosis, or reduction division, is the form of
treatment for patients with breast cancer and cell division that only occurs in the gonads (see
also in carcinoma of the kidney. Progestogens GONAD) that is, the testis (see TESTICLE) and
have been proposed for lessening premenstrual the ovary (see OVARIES) giving rise to the germ
symptoms, but proof of their value in this role cells (gametes) of the sperms (see SPERMATO-
is not convincing. ZOON) and the ova (see OVUM).
Two types of sperm cells are produced: one
Medulla contains 22 autosomes and a Y sex chromosome
The inside part of an organ or tissue that is (see SEX CHROMOSOMES); the other, 22 auto-
distinct from the outer part for example, the somes and an X sex chromosome. All the ova,
marrow in the centre of a long bone, or the however, produced by normal meiosis have 22
inner portion of the kidneys or adrenal glands. autosomes and an X sex chromosome.
 442 Meiosis

The formation of gametes. Top, normal meiosis. Centre, non-disjunction at first meiotic division. Bottom,
non-disjunction at second meiotic division.

Two divisions of the NUCLEUS occur (see also change can take place between the chromatids
CELLS) and only one division of the chromo- and in this way new combinations of GENES
somes, so that the number of chromosomes in arise. All four chromatids are closely inter-
the ova and sperms is half that of the somatic woven and recombination may take place
cells. Each chromosome pair divides so that the between any maternal or any paternal chro-
gametes receive only one member of each pair. matids. This process is known as crossing over
The number of chromosomes is restored to full or recombination. After this period of inter-
complement at fertilisation so that the zygote change, homologous chromosomes move
has a complete set, each chromosome from the apart, one to each pole of the nucleus. The
nucleus of the sperm pairing up with its corres- cell then divides and the nucleus of each new
ponding partner from the ovum. cell now contains 23 and not 46 chromo-
The first stage of meiosis involves the pair- somes. The second meiotic division then
ing of homologous chromosomes which join occurs, the centromeres divide and the chro-
together and synapse lengthwise. The chromo- matids move apart to opposite poles of the
somes then become doubled by splitting along nucleus so there are still 23 chromosomes in
their length and the chromatids so formed are each of the daughter nuclei so formed. The
held together by centromeres. As the hom- cell divides again so that there are four gam-
ologous chromosomes one of which has etes, each containing a half number (haploid)
come from the mother, and the other from set of chromosomes. However, owing to the
the father are lying together, genetic inter- recombination or crossing over, the genetic
 Memory 443

material is not identical with either parent or depth of invasion. Very superficial melanomas
with other spermatozoa. carry an excellent outlook once removed, but
deeper tumours may spread to regional lymph
Melaena glands and beyond with fatal results. Public-
Blood in the FAECES in which dark, tarry masses awareness campaigns have led to the earlier pre-
are passed from the bowel. It is due to bleeding sentation of melanomas in recent years, with
from the stomach or from the higher part of the corresponding benefit. (See also SUNBURN.)
bowel, the blood undergoing chemical changes
under the action of the secretions, and being Melatonin
finally converted in large part into sulphide of A hormone that plays a key role in the bodys
iron. It is a serious symptom meriting medical diurnal (night and day) rhythms. Produced by
investigation. It can indicate peptic ulcer or car- the PINEAL GLAND and derived from SERO-
cinoma of the stomach. TONIN, it acts on receptors in an area of the
brain above the OPTIC CHIASMA, synchronising
Melancholia them to the diurnal rhythm. Melatonin is
A term used in the past for illness characterised under investigation as a possible agent to treat
by great mental and physical DEPRESSION. (See insomnia in the elderly, in shift workers and in
MENTAL ILLNESS.) those with severe learning disability (mental
handicap). It may also help people with SEA-
Melanin SONAL AFFECTIVE DISORDER SYNDROME
Pigment which confers colour on the SKIN, hair (SADS) and those who suffer from jet lag.
and EYE. It is produced by cells called melano-
cytes interspersed along the basal layer of the Melphalan
EPIDERMIS. The maturation of the epidermis One of the ALKYLATING AGENTS, melphalan is
into stratum corneum cells packed with mel- used to treat certain forms of malignant disease
anin granules confers an ultraviolet light barrier including breast tumours (see BREASTS, DISEASES
which protects the skin against the harmful OF), MELANOMA and Hodgkins LYMPHOMA. It
effects resulting from continued solar exposure. can be given orally or by injection. (See
The races do not differ in the number of CYTOTOXIC.)
M
melanocytes in their skin, only in the rate and
quantity of melanin production. Exposure to Membranes
bright sunlight stimulates melanin production See BRAIN; CROUP; DIPHTHERIA; labour (under
and distribution causing suntan. A hormone PREGNANCY AND LABOUR).
from the PITUITARY GLAND may stimulate mel-
anin production on the face in pregnancy (see Memory
CHLOASMA). The capacity to remember. It is a complex pro-
cess and probably occurs in many areas of the
Melanocyte BRAIN including the LIMBIC SYSTEM and the
Clear branching cell in the epidermis of the temporal lobes. There are three main steps:
SKIN that produces tyrosinase (an ENZYME) and registration, storage, and recall.
MELANIN. During registration, information from the
sense organs and the cerebral cortex is put into
Melanoma codes for storage in the short-term memory sys-
A malignant tumour arising from melanocytes tem. The codes are usually acoustic (based on
(see MELANOCYTE). It may start in an existing the sounds and words that would be used to
MOLE or arise de novo. Increasing exposure to describe the information) but may use any of
sunlight of white populations in the 20th cen- the five senses. This system can take only a few
tury has resulted in an alarming increase in the chunks of information at a time: for example,
incidence of this cancer. It is mainly seen in only about seven longish numbers can be
those over 40 years, especially on the legs in retained and recalled at once the next new
women and on the back in men. An enlarging number displaces an earlier one that is then for-
pigmented macule or nodule with irregular gotten. And if a subject is asked to describe a
contour, profile or colour distribution is always person just met, he or she will recall only seven
suspect. or so facts about that person. This depends on
attention span and can be improved by concen-
Treatment is excision with a margin of nor- tration and rehearsal for example, by reciting
mal tissue. The specimen must be examined the list of things that must be remembered.
histologically, and prognosis depends on the Material needing storage for several minutes
 444 Menarche

stays in the short-term memory. More valuable istics are classed as either dominant or recessive.
information goes to the long-term memory The offspring of the first generation tend to
where it can be kept for any period from a few inherit the dominant characteristics, whilst the
minutes to a lifetime. Storage is more reliable if recessive characteristics remain latent and
the information is in meaningful codes it is appear in some of the offspring of the second
much easier to remember peoples names if generation. If individuals possessing recessive
their faces and personalities are memorable too. characters unite, recessive characters then
Using techniques such as mnemonics takes this become dominant characters in succeeding
into account. generations. (See GENETICS.)
The final stage is retrieval. Recognising and
recalling the required information involves Mendelson Syndrome
searching the memory. In the short-term Inhalation of regurgitated stomach contents,
memory, this takes about 40-thousandths of a usually as a complication of general ANAES-
second per item a rate that is surprisingly THESIA. It may cause death from ANOXIA or
consistent, even in people with disorders such result in extensive lung damage.
as SCHIZOPHRENIA.
Most kinds of forgetting or AMNESIA occur Menires Disease
during retrieval. Benign forgetfulness is usually Named after the Frenchman, Prosper
caused by interference from similar items Menire, who first described it in 1861, the
because the required information was not disease is characterised by TINNITUS, deafness
clearly coded and well organised. Retrieval can and intermittent attacks of VERTIGO. The first
be improved by recreating the context in which manifestation is usually deafness on one side;
the information was registered. This is why the then as a rule, many months later there is
police reconstruct scenes of crimes, and why a sudden attack, without any warning, of
revision for exams is more effective if facts are intense vertigo. The acute giddiness usually
learnt in the form of answers to mock lasts for two or three hours with some
questions. unsteadiness persisting for a few days. The
Loss of memory or amnesia mainly affects time interval between attacks varies from a
M long-term memory (information which is week to a few months. When they do recur,
stored indefinitely) rather than short-term they tend to do so in clusters. The tinnitus,
memory which is measured in minutes. Short- which tends to be low-pitched, comes on at
term memory may, however, be affected by about the same time as the deafness; it is
unconsciousness caused by trauma. Drivers often described as being like rushing water or
involved in an accident may be unable to recall escaping steam. The deafness becomes grad-
the event or the period leading up to it. The ually worse until it is complete. The condi-
cause of amnesia is disease of or damage to the tion is due to excessive fluid in the labyrinth
parts of the brain responsible for memory. of the ears (see EAR). The cause of this
Degenerative disorders such as ALZHEIMERS accumulation is not known, although it has
DISEASE, brain tumours, infections (for been suggested that it might be a form of
example, ENCEPHALITIS), STROKE, SUBARACH- ALLERGY, or might be due to spasm of small
NOID HAEMORRHAGE and alcoholism all cause blood vessels. The disorder is diagnosed from
memory loss. Some psychiatric illnesses feature AUDIOMETRY, the CALORIC TEST and other
loss of memory and AGEING is usually accom- investigations.
panied by some memory loss, although the age
of onset and severity vary greatly. Treatment Acute vertigo symptoms can
sometimes be alleviated with drugs such as
Menarche CYCLIZINE HYDROCHLORIDE and NICOTINIC
The start of MENSTRUATION. The average age at ACID, but the disorder is notoriously difficult to
which it occurs in British females is 125 years treat and no certain cure is available. Surgical
a year or two after the first physical indications decompression of the fluid in the ears bal-
of PUBERTY start. There is considerable racial ancing mechanism may relieve vertigo and pre-
and geographical variation. vent the disease from worsening. The vestibular
nerve to the ear can also be cut to relieve vertigo
Mendelism while preserving hearing.
The term applied to a law enunciated by G. J.
Mendel that the offspring is not intermediate in Meninges
type between its parents, but that the type of The membranes surrounding the BRAIN and
one or other parent is predominant. Character- SPINAL CORD. The membranes include the
 Meningitis 445

DURA MATER, a tough, fibrous membrane large number of cases in the UK, while group A
closely applied to the inside of the skull; the is less common.
ARACHNOID MEMBRANE, a more delicate mem- Bacterial meningitis may occur by spread
brane, enveloping the brain but separated from from nearby infected foci such as the nasophar-
its irregular surface by spaces containing fluid; ynx, middle ear, mastoid and sinuses (see EAR,
and the pia mater, a delicate network of fibres DISEASES OF). Direct infection may be the result
containing blood vessels and uniting the arach- of penetrating injuries of the skull from acci-
noid to the brain. The latter two are sometimes dents or gunshot wounds. Meningitis may also
referred to as the pia-arachnoid. be a complication of neurosurgery despite care-
These membranes bear the blood vessels ful aseptic precautions. Immuno-compromised
which nourish the surface of the brain and the patients those with AIDS or on CYTOTOXIC
interior of the skull. Meningeal haemorrhage drugs are vulnerable to infections.
from these vessels forms one of the chief dan- Spread to contacts may occur in schools and
gers arising from fracture of the skull. similar communities. Many people harbour the
meningococcus without developing meningitis.
Meningism In recent years small clusters of cases, mainly in
A condition with symptoms and signs closely schoolchildren and young people at college,
resembling those of MENINGITIS. Most com- have occurred in Britain.
monly occurring in children, it is usually a Symptoms include malaise accompanied by
symptom of chest infection or of inflammation fever, severe headache, PHOTOPHOBIA, vomit-
in the upper respiratory tract. Given the serious ing, irritability, rigors, drowsiness and neuro-
implications of meningitis, medical advice logical disturbances. Neck stiffness and a
should be sought. Examination of the CERE- positive KERNIGS SIGN appearing within a few
BROSPINAL FLUID may be necessary: in mening- hours of infection are key diagnostic signs.
ism the fluid is normal. Meningococcal and pneumococcal meningitis
may co-exist with SEPTICAEMIA, a much more
Meningitis serious condition in terms of death rate or
Inflammation affecting the membranes of the organ damage and which constitutes a grave
BRAIN or SPINAL CORD, or usually both. Men- emergency demanding rapid treatment. M
ingitis may be caused by BACTERIA, viruses (see
VIRUS), fungi, malignant cells or blood (after Diagnosis and treatment are urgent and,
SUBARACHNOID HAEMORRHAGE). The term is, if bacterial meningitis is suspected, antibiotic
however, usually restricted to inflammation due treatment should be started even before labora-
to a bacterium or virus. Viral meningitis is tory confirmation of the infection. Analysis of
normally a mild, self-limiting infection of a few the CEREBROSPINAL FLUID (CSF) by means of a
days duration; it is the most common cause of LUMBAR PUNCTURE is an essential step in diag-
meningitis but usually results in complete nosis, except in patients for whom the test
recovery and requires no specific treatment. would be dangerous as they have signs of raised
Usually a less serious infection than the bac- intracranial pressure. The CSF is clear or turbid
terial variety, it does, however, rarely cause in viral meningitis, turbid or viscous in tubercu-
associated ENCEPHALITIS, which is a potentially lous infection and turbulent or purulent when
dangerous illness. A range of viruses can cause meningococci or staphylococci are the infective
meningitis, including: ENTEROVIRUSES; those agents. Cell counts and biochemical make-up
causing MUMPS, INFLUENZA and HERPES SIM- of the CSF are other diagnostic pointers. Sero-
PLEX; and HIV. logical tests are done to identify possible syphil-
Bacterial meningitis is life-threatening: in the itic infection, which is now rare in Britain.
United Kingdom, 510 per cent of children Patients with suspected meningitis should be
who contract the disease may die. Most cases of admitted to hospital quickly. General pracition-
acute bacterial meningitis in the UK are caused ers are encouraged to give a dose of intra-
by two bacteria: Neisseria meningitidis (menin- muscular penicillin before sending the child to
gococcus), and Streptococcus pneumoniae hospital. Treatment in hospital is usually with a
(pneumococcus); other bacteria include Hae- cephalosporin, such as ceftazidime or ceftriax-
mophilus influenzae (a common cause until vir- one. Once the sensitivity of the organism is
tually wiped out by immunisation), Escherichia known as a result of laboratory studies on CSF
coli, Mycobacterium tuberculosis (see TUBERCU- and blood, this may be changed to penicillin or,
LOSIS), Treponema pallidum (see SYPHILIS) and in the case of H. influenzae, to amoxicillin.
Staphylococci spp. Of the bacterial infections, Local infections such as SINUSITIS or middle-ear
meningococcal group B is the type that causes a infection require treatment, and appropriate
 446 Meningocele

surgery for skull fractures or meningeal tears the brain and the underlying brain matter. In
should be carried out as necessary. Tuberculous practically all cases of MENINGITIS there is some
meningitis is treated for at least nine months involvement of the underlying brain, and it is
with anti-tuberculous drugs (see TUBERCU- when this involvement is considerable that the
LOSIS). If bacterial meningitis causes CONVUL- term, meningoencephalitis, is used. One form
SIONS, these can be controlled with diazepam that has attracted attention in recent years is
(see TRANQUILLISERS; BENZODIAZEPINES) and that caused by amoebae (see AMOEBA), particu-
ANALGESICS will be required for the severe larly that known as Naegleria fowleri, in which
headache. the infection is acquired through bathing in
Coexisting septicaemia may require full contaminated water. Effective chlorination of
intensive care with close attention to intraven- swimming baths kills this micro-organism.
ous fluid and electrolyte balance, control of
blood clotting and blood pressure. Meningomyelocele
Treatment of close contacts such as family, A protrusion of the MENINGES of the spinal
school friends, medical and nursing staff is cord through a defect in the spine. (See SPINA
recommended if the patient has H. influenzae BIFIDA.)
or N. meningitidis: RIFAMPICIN provides effect-
ive prophylaxis. Contacts of patients with Meniscus
pneumococcal infection do not need preventive A crescentic fibro-cartilage in a joint, such as
treatment. Vaccines for meningococcal menin- the cartilages in the knee-joint.
gitis may be given to family members in small
epidemics and to any contacts who are espe- Menopause
cially at risk such as infants, the elderly and This is the term applied to the cessation of
immuno-compromised individuals. MENSTRUATION at the end of reproductive life.
The outlook for a patient with bacterial men- Usually it occurs between the ages of 45 and 50,
ingitis depends upon age the young and old although it may occur before the age of 30 or
are vulnerable; speed of onset sudden onset after the age of 50. It can be a psychologically
worsens the prognosis; and how quickly treat- disturbing experience which is quite often
M ment is started hence the urgency of diagnosis accompanied by physical manifestations. These
and admission to hospital. Recent research has include hot flushes, tiredness, irritability, lack of
shown that children who suffer meningitis in concentration, palpitations, aching joints and
their first year of life are ten times more likely to vaginal irritation. There may also be loss of
develop moderate or severe disability by the age libido (sex drive). Most women can and do live
of five than contemporaries who have not been happy, active lives through the menopause, the
infected. (See British Medical Journal, 8 Sep- length of which varies considerably.
tember 2001, page 523.) One of the major problems of the meno-
pause which does not give rise to symptoms
Prevention One type of bacterial meningitis, until many years later is osteoporosis (see BONE,
that caused by Haemophilus, has been largely DISORDERS OF). After the menopause, 1 per
controlled by IMMUNISATION; meningococcal cent of the bone is lost per annum to the end of
C vaccine has largely prevented this type of the life. This is a factor in the frequency of fractures
disease in the UK. So far, no vaccine against of the femur in elderly women as a result of
group B has been developed, but research con- osetoporosis, but it can be prevented by
tinues. Information on meningitis can be hormone replacement therapy (see below).
obtained from the Meningitis Trust and the
Meningitis Research Foundation. Hormone replacement therapy
(HRT) This term has become synonymous
Meningocele with the scientifically correct term OESTRO-
Meningocele is a protusion of the MENINGES of GENS replacement therapy to signify the treat-
the brain through a defect in the skull. (See ment of menopausal symptoms and signs with
SPINA BIFIDA.) oestrogens, now usually combined with PRO-
GESTOGEN. Oestrogen and combined treat-
Meningococcus ment relieve the short-term symptoms such as
See NEISSERIACEAE. hot flushes, sweats and vaginal dryness.
Atrophic vaginitis and vulvitis (shrinking of the
Meningoencephalitis tissues of VULVA and VAGINA due to fall in nat-
Meningoencephalitis is the term applied to ural oestrogen levels) also usually respond to
infection of the membranes, or MENINGES, of treatment with oestrogens.
 Menstruation 447

Cyclical therapy is necessary to avoid recommended for women who smoke heavily
abnormal bleeding in women who have reached or have had THROMBOSIS, severe HYPERTEN-
the menopause. If oestrogens are given alone, SION, stroke or liver disease. HRT has, how-
there is an increased risk of endometrial hyper- ever, brought symptomatic benefits to many
plasia (overgrowth of the ENDOMETRIUM) menopausal women, who can then justify tak-
which may lead to endometrial cancer, so these ing the other increased risks only fully under-
are restricted to women who have had a hyster- stood since the large trial results were
ectomy and are no longer at risk. Other women published.
can be given oestrogen-progestogen As the evidence stands at present, careful
combinations. consideration of each womans medical history
There is good evidence that oestrogen alone and the severity of her menopausal symptoms is
or in combination can prevent the bone-loss necessary in deciding what combination of
associated with the menopause by reducing the drugs should be given and for how long. In
demineralisation of bone which normally general, the indications should be severe meno-
occurs after the menopause; and, if it is started pausal symptoms that can be controlled by the
early and continued for years, it may prevent lowest dose for the shortest time. Using HRT to
the development of osteoporosis. Oestrogen is alleviate mild symptoms, or to prevent future
far more effective than calcium supplements bone loss, is probably of insufficient benefit to
and has been shown greatly to reduce fractures counter the other risks described above.
affecting the spine, wrists and legs after the age
of 50. Menorrhagia
However, HRT is no longer licensed for first- Menorrhagia means an over-abundance of the
line treatment to prevent osteoporosis, as menstrual discharge. (See MENSTRUATION, DIS-
increased risk of stroke, breast cancer and cor- ORDERS OF.)
onary heart disease cannot justify treatment for
long periods unless the woman has severe Menstruation
menopausal symptoms. HRT is recommended A periodic change occurring in (female) human
for short-term use only in menopausal women beings and the higher apes, consisting chiefly in
whose lives are inconvenienced by vasomotor a flow of blood from the cavity of the womb M
instability (severe flushes, etc.) or vaginal atro- (UTERUS) and associated with various slight
phy, although the latter may respond to local constitutional disturbances. It begins between
oestrogen treatment creams or pessaries. In the ages of 12 and 15, as a rule although its
terms of oestrogenic activity, natural oestrogen onset may be delayed until as late as 20, or it
such as oestradiol, oestrone and oestriol are may begin as early as ten or 11. Along with its
more appropriate for HRT than synthetic oes- first appearance, the body develops the
trogens like ethinyloestradiol, mestranol and secondary sex characteristics: for example,
diethylstilboestrol. enlargement of the BREASTS, and characteristic
Many experts believe that controversy sur- hair distribution. The duration of each men-
rounding the risks and benefits of HRT have strual period varies in different persons from 2
been settled by a large randomised trial (the 8 days. It recurs in the great majority of cases
Womens Health Initiative), published in 2003, with regularity, most commonly at intervals of
which showed that combined treatment 28 or 30 days, less often with intervals of 21 or
increases the risk of breast tumours, stroke and 27 days, and ceasing only during pregnancy and
coronary heart disease (in the first year). Oes- lactation, until the age of 45 or 50 arrives, when
trogen alone (given to women who have had a it stops altogether as a rule ceasing early if it
hysterectomy) also increases the risk of stroke. has begun early, and vice versa. The final stop-
Five years of combined treatment may double page is known as the MENOPAUSE or the
the risk of breast cancer, and the heart-disease CLIMACTERIC.
risk is nearly doubled during the first year of Menstruation depends upon a functioning
use. This is in spite of the beneficial effects of ovary (see OVARIES) and this upon a healthy
HRT on blood lipids. However, there are others PITUITARY GLAND. The regular rhythm may
who consider that different dose combinations depend upon a centre in the HYPOTHALAMUS,
of different hormones may one day prove bene- which is in close connection with the pituitary.
ficial, so research continues. After menstruation, the denuded uterine
HRT can also provoke minor adverse effects ENDOMETRIUM is regenerated under the influ-
such as breast tenderness, fluid retention, leg ence of the follicular hormone, oestradiol. The
cramps and nausea. The risk of abnormal blood epithelium of the endometrium proliferates,
clotting means that HRT is not normally and about a fortnight after the beginning of
 448 Menstruation

menstruation great development of the endo- weight loss is the cause of amenorrhoea, restor-
metrial glands takes place under the influence ation of body weight alone can result in
of progesterone, the hormone secreted by the spontaneous menstruation (see also EATING
CORPUS LUTEUM. These changes are made for DISORDERS Anorexia nervosa). Patients with
the reception of the fertilised OVUM. In the raised concentration of serum gonadotrophin
absence of fertilisation the uterine endo- hormones have primary ovarian failure, and this
metrium breaks down in the subsequent men- is not amenable to treatment. Cyclical oestro-
strual discharge. gen/progestogen therapy will usually establish
withdrawal bleeding. If the amenorrhoea is due
Disorders of menstruation In most to mild pituitary failure, menstruation may
healthy women, menstruation proceeds regu- return after treatment with clomiphene, a non-
larly for 30 years or more, with the exceptions steroidal agent which competes for oestrogen
connected with childbirth. In many women, receptors in the hypothalamus. The patients
however, menstruation may be absent, excessive who are most likely to respond to clomiphene
or painful. The term amenorrhoea is applied to are those who have some evidence of endogen-
the condition of absent menstruation; the terms ous oestrogen and gonadotrophin production.
menorrhagia and metrorrhagia describe exces- IRREGULAR MENSTRUATION This is a change
sive menstrual loss the former if the excess from the normal monthly cycle of menstru-
occurs at the regular periods, and the latter if it ation, the duration of bleeding or the amount
is irregular. Dysmenorrhoea is the name given of blood lost (see menorrhagia, below). Such
to painful menstruation. changes may be the result of an upset in the
AMENORRHOEA If menstruation has never balance of oestrogen and progesterone hor-
occurred, the amenorrhoea is termed primary; mones which between them control the cycle.
if it ceases after having once become established Cycles may be irregular after the MENARCHE
it is known as secondary amenorrhoea. The and before the menopause. Unsuspected preg-
only value of these terms is that some patients nancy may manifest itself as an irregularity, as
with either chromosomal abnormalities (see can an early miscarriage (see ABORTION). Dis-
CHROMOSOMES) or malformations of the geni- orders of the uterus, ovaries or organs in the
M tal tract fall into the primary category. Other- pelvic cavity can also cause irregular menstru-
wise, the age of onset of symptoms is more ation. Women with the condition should seek
important. medical advice.
The causes of amenorrhoea are numerous MENORRHAGIA Abnormal bleeding from the
and treatment requires dealing with the pri- uterus during menstruation. A woman loses on
mary cause. The commonest cause is preg- average about 60 ml of blood during her
nancy; psychological stress or eating disorders period; in menorrhagia this can rise to 100 ml.
can cause amenorrhoea, as can poor nutrition Some women have this problem occasionally,
or loss of weight by dieting, and any serious some quite frequently and others never. One
underlying disease such as TUBERCULOSIS or cause is an imbalance of progesterone and oes-
MALARIA. The excess secretion of PROLACTIN, trogen hormones which between them control
whether this is the result of a micro-adenoma of menstruation: the result is an abnormal increase
the pituitary gland or whether it is drug in the lining (endometrium) of the uterus,
induced, will cause amenorrhoea and possibly which increases the amount of bleeding tissue.
GALACTORRHOEA as well. Malfunction of the Other causes include fibroids, polyps, pelvic
pituitary gland will result in a failure to produce infection or an intrauterine contraceptive
the gonadotrophic hormones (see GONADO- device (IUD see under CONTRACEPTION).
TROPHINS) with consequent amenorrhoea. Sometimes no physical reason for menorrhagia
Excessive production of cortisol, as in CUSH- can be identified.
INGS SYNDROME, or of androgens (see ANDRO- Treatment of the disorder will depend on
GEN) as in the adreno-genital syndrome or the how severe the loss of blood is (some women
polycystic ovary syndrome will result in amen- will become anaemic see ANAEMIA and
orrhoea. Amenorrhoea occasionally follows use require iron-replacement therapy); the womans
of the oral contraceptive pill and may be associ- age; the cause of heavy bleeding; and whether
ated with both hypothyroidism (see under THY- or not she wants children. An increase in men-
ROID GLAND, DISEASES OF) and OBESITY. strual bleeding may occur in the months before
Patients should be reassured that amenor- the menopause, in which case time may pro-
rhoea can often be successfully treated and does duce a cure. Medical or surgical treatments are
not necessarily affect their ability to have nor- available. Non-steroidal anti-inflammatory
mal sexual relations and to conceive. When drugs may help, as may tranexamic acid, which
 Mental Illness 449

prevents the breakdown of blood clots in the tending to respond to certain treatments. The
circulation (FIBRINOLYSIS): this drug can be idea that illnesses can be diagnosed simply by
helpful if an IUD is causing bleeding. Hor- recognising their symptom patterns may not
mones such as dydrogesterone (by mouth) may seem very scientific in these days of high tech-
cure the condition, as may an IUD that releases nology. For most common mental illnesses,
small quantities of a PROGESTOGEN into the lin- however, this is the only method of diagnosis;
ing of the womb. whatever is going wrong in the brain is usually
Traditionally, surgical intervention was either too poorly understood and too subtle to show
dilatation and curettage of the womb lining (D up in laboratory tests or computed tomography
& C) or removal of the whole uterus (HYSTER- scans of the brain. And symptom-based def-
ECTOMY). Most surgery is now done using min- initions of mental illnesses are, generally, a lot
imally invasive techniques. These do not more meaningful than the vague lay term ner-
require the abdomen to be cut open, as an vous breakdown, which is used to cover an
ENDOSCOPE is passed via the vagina into the attack of anything from AGORAPHOBIA to total
uterus. Using DIATHERMY or a laser, the surgeon inability to function.
then removes the whole lining of the womb. There is still a lot to learn about the workings
DYSMENORRHOEA This varies from discomfort of the brain, but psychiatry has developed
to serious pain, and sometimes includes vomit- plenty of practical knowledge about the prob-
ing and general malaise. Anaemia is sometimes able causes of mental illness, ways of relieving
a cause of painful menstruation as well as of symptoms, and ways of aiding recovery. Most
stoppage of this function. experts now believe that mental illnesses gener-
Inflammation of the uterus, ovaries or FAL- ally arise from different combinations of
LOPIAN TUBES is a common cause of dysmenor- inherited risk and psychological STRESS, some-
rhoea which comes on for the first time late in times with additional environmental exposure
life, especially when the trouble follows the for example, viruses, drugs or ALCOHOL.
birth of a child. In this case the pain exists more The range of common mental illnesses
or less at all times, but is aggravated at the includes anxiety states, PHOBIA, DEPRESSION,
periods. Treatment with analgesics and remedy- alcohol and drug problems, the EATING DIS-
ing the underlying cause is called for. ORDERS anorexia and bulimia nervosa, MANIC
M
Many cases of dysmenorrhoea appear with DEPRESSION, SCHIZOPHRENIA, DEMENTIA, and
the beginning of menstrual life, and accompany a group of problems related to coping with life
every period. It has been estimated that 510 that psychiatrists call personality disorders.
per cent of girls in their late teens or early 20s Of these mental illnesses, dementia is the
are severely incapacitated by dysmenorrhoea for best understood. It is an irreversible and fatal
several hours each month. Various causes have form of mental deterioration (starting with for-
been suggested for the pain, one being an exces- getfulness and eventually leading to severe fail-
sive production of PROSTAGLANDINS. There ure of all the brains functions), caused by rapid
may be a psychological factor in some sufferers death of brain cells and consequent brain
and, whether this is the result of inadequate shrinkage. Schizophrenia is another serious
sex instruction, fear, family, school or work mental illness which disrupts thought-
problems, it is important to offer advice and processes, speech, emotions and perception
support, which in itself may resolve the dys- (how the brain handles signals from the five
menorrhoea. Symptomatic relief is of value. senses). Manic depression, in which prolonged
highs of extremely elevated mood and over-
Mental Handicap excitement alternate with abject misery, has
See LEARNING DISABILITY. similar effects on the mental processes. In both
schizophrenia and manic depression the sufferer
Mental Illness loses touch with reality, develops unshakeable
Defined simply, this is a disorder of the brains but completely unrealistic ideas (delusions),
processes that makes the sufferer feel or seem ill, and hallucinates (vividly experiences sensations
and may prevent that person from coping with that are not real, e.g. hears voices when there is
daily life. Psychiatrists doctors specialising in nobody there). This triad of symptoms is called
diagnosing and treating mental illness have, psychosis and it is what lay people, through fear
however, come up with a range of much more and lack of understanding, sometimes call
complicated definitions over the years. lunacy, madness or insanity.
Psychiatrists like to categorise mental ill- The other mental illnesses mentioned above
nesses because mental signs and symptoms do are sometimes called neuroses. But the term has
occur together in clusters or syndromes, each become derogatory in ordinary lay language;
 450 Mental Illness

indeed, many people assume that neuroses are what the people they see are normally like and
mild disorders that only affect weak people who what kind of lives they have led. These ques-
cannot pull themselves together, while psych- tions may seem unnecessarily intrusive, but
oses are always severe. In reality, psychoses can they allow psychiatrists to understand patients
be brief and reversible and neuroses can cause problems and decide on the best way to help
lifelong disability. them.
However defined and categorised, mental ill- The next stage in assessment is the mental-
ness is a big public-health problem. In the UK, state examination. This is how psychiatrists
up to one in five women and around one in examine minds, or at least their current state.
seven men have had mental illness. About half a Mental-state examination entails asking more
million people in Britain suffer from schizo- questions and using careful observation to
phrenia: it is three times commoner than can- assess feelings, thoughts and mental symptoms,
cer. And at any one time, up to a tenth of the as well as the way the mind is working (for
adult population is ill with depression. example, in terms of memory and concentra-
tion). During first consultations psychiatrists
Treatment settings Most people with usually make diagnoses and explain them. The
mental-health problems get the help they need boundary between a life problem that will clear
from their own family doctor(s), without ever up spontaneously and a mental illness that
seeing a psychiatrist. General practictitioners in needs treatment is sometimes quite blurred; one
Britain treat nine out of ten recognised mental- consultation may be enough to put the problem
health problems and see around 12 million in perspective and help to solve it.
adults with mental illness each year. Even for Further assessment in the clinic may be
the one in ten of these patients referred to psy- needed, or some additional tests. Simple blood
chiatrists, general practitioners usually handle tests can be done in outpatient clinics but other
those problems that continue or recur. investigations will mean referral to another
Psychiatrists, psychiatric nurses, social work- department, usually on another day.
ers, psychologists, counsellors and therapists
often see patients at local doctors surgeries and Further assessment and tests
M will do home visits if necessary. Community PSYCHOLOGICAL TESTS Psychologists work in
mental-health centres like general-practice or alongside the psychiatric team, helping in
health centres but catering solely for mental- both assessment and treatment. The range of
health problems offer another short-cut to psychological tests studies memory, intelli-
psychiatric help. The more traditional, and still gence, personality, perception and capability for
more common, route to a psychiatrist for many abstract thinking.
people, however, is from the general practiti- PHYSICAL TESTS Blood tests and brain scans
tioner to a hospital outpatient department. may be useful to rule out a physical illness caus-
ing psychological symptoms.
Specialist psychiatric help In many SOCIAL ASSESSMENT Many patients have social
ways, a visit to a psychiatrist is much like any difficulties that can be teased out and helped by
trip to a hospital doctor and, indeed, psychi- a psychiatric social worker. Approved social
atric clinics are often based in the outpatient workers have special training in the use of the
departments of general hospitals. First Mental Health Act, the law that authorises
appointments with psychiatrists can last an compulsory admissions to psychiatric hospitals
hour or more because the psychiatrist and and compulsory psychiatric treatments. These
sometimes other members of the team such as social workers also know about all the mental-
nurses, doctors in training, and social workers health services offered by local councils and
need to ask lots of questions and record the voluntary organisations, and can refer clients to
whole consultation in a set of confidential case them. The role of some social workers has been
notes. widened greatly in recent years by the expan-
Psychiatric assessment usually includes an sion of community care.
interview and an examination, and is some- OCCUPATIONAL THERAPY ASSESSMENT Mental-
times backed up by a range of tests. The inter- health problems causing practical disabilities
view begins with the patients history the for instance, inability to work, cook or look
personal story that explains how and, to some after oneself can be assessed and helped by
extent, why help is needed now. Mental-health occupational therapists.
problems almost invariably develop from a mix-
ture of causes emotional, social, physical and Treatment The aims of psychiatric treatment
familial and it helps psychiatrists to know are to help sufferers shake off, or at least cope
 Mental Illness 451

with, symptoms and to gain or regain an mended doses are not exceeded although one
acceptable quality of life. A range of psycho- group, the monoamine oxidase inhibitors, can
logical and physical treatments is available. lead to sudden and dangerous high blood pres-
sure if taken with certain foods.
COUNSELLING This is a widely used talking Manic depression virtually always has to be
cure, particularly in general practice. Counsel- treated with mood-stabilising drugs. Lithium
lors listen to their clients, help them to explore carbonate is used in acute mania to lower mood
feelings, and help them to find personal and and stop psychotic symptoms; it can also be
practical solutions to their problems. Counsel- used in severe depression. However lithiums
lors do not probe into clients pasts or analyse main use is to prevent relapse in manic depres-
them. sion. Long-term unwanted effects may include
PSYCHOTHERAPY This is the best known talk- kidney and thyroid problems, and short-term
ing cure. The term psychotherapy is a general- problems in the nervous system and kidney
isation covering many different concepts. They may occur if the blood concentration of lithium
all started, however, with Sigmund Freud (see is too high therefore it must be monitored by
FREUDIAN THEORY), the father of modern psy- regular blood tests. Carbamazepine, a treatment
chotherapy. Freud was a doctor who discovered for EPILEPSY, has also been found to stabilise
that, as well as the conscious thoughts that mood, and also necessitates blood tests.
guide our feelings and actions, there are power- Antipsychotic drugs, also called neuroleptics,
ful psychological forces of which we are not and major tranquillisers are the only effective
usually aware. Applying his theories to his treatments for relieving serious mental illnesses
patients freely expressed thoughts, Freud was with hallucinations and delusions. They are
able to cure many illnesses, some of which had used mainly in schizophrenia and include the
been presumed completely physical. This was short-acting drugs chlorpromazine and clozap-
the beginning of individual analytical psycho- ine as well as the long-lasting injections
therapy, or PSYCHOANALYSIS. Although Freuds given once every few weeks like fluphenazine
principles underpin all subsequent theories decanoate. In the long term, however, some of
about the psyche, many different schools of the older antipsychotic drugs can cause a brain
thought have emerged and influenced psycho- problem called TARDIVE DYSKINESIA that affects M
therapists (see ADLER; JUNGIAN ANALYSIS; control of movement and is not always revers-
PSYCHOTHERAPY). ible. And the antipsychotic drugs short-term
BEHAVIOUR THERAPY This springs from theor- side-effects such as shaking and stiffness some-
ies of human behaviour, many of which are times have to be counteracted by other drugs
based on studies of animals. The therapists, called anticholinergic drugs such as procyclid-
mostly psychologists, help people to look at ine and benzhexol. Newer antipsychotic drugs
problematic patterns of behaviour and thought, such as clozapine do not cause tardive dyski-
and to change them. Cognitive therapy is very nesia, but clozapine cannot be given as a long-
effective, particularly in depression and eating lasting injection and its concentration in the
disorders. body has to be monitored by regular blood tests
PHYSICAL TREATMENTS The most widely used to avoid toxicity.
physical treatments in psychiatry are drugs. OTHER PHYSICAL TREATMENTS The other two
Tranquillising and anxiety-reducing BENZO- physical treatments used in psychiatry are par-
DIAZEPINES like diazepam, well known by its ticularly controversial: electroconvulsive ther-
trade name of Valium, were prescribed widely apy (ECT) and psychosurgery. In ECT, which
in the 1960s and 70s because they seemed an can be life-saving for patients who have severe
effective and safe substitute for barbiturates. life-threatening depression, a small electric cur-
Benzodiazepines are, however, addictive and rent is passed through the brain to induce a fit
are now recommended only for short-term or seizure. Before the treatment the patient is
relief of anxiety that is severe, disabling, or anaesthetised and given a muscle-relaxing injec-
unacceptably distressing. They are also used for tion that reduces the magnitude of the fit to a
short-term treatment of patients drying out slight twitching or shaking. Scientists do not
from alcohol. really understand how ECT works, but it does,
ANTIDEPRESSANT DRUGS like amitriptyline for carefully selected patients. Psychosurgery
and fluoxetine are given to lift depressed mood operating on the brain to alleviate psychiatric
and to relieve the physical symptoms that some- illness or difficult personality traits is
times occur in depression, such as insomnia and extremely uncommon these days. Stereo-tactic
poor appetite. The side-effects of antidepres- surgery, in which small cuts are made in specific
sants are mostly relatively mild, when recom- brain fibres under X-ray guidance, has super-
 452 Mental Illness

seded the more generalised lobotomies of ers who can visit patients urgently at home (at a
old. The Mental Health Act 1983 ensures that GPs request) and, sometimes, avert unneces-
psychosurgery is performed only when the sary admission. And research has shown that
patient has given fully informed consent and a home treatment for a range of acute psychiatric
second medical opinion has agreed that it is problems can be effective.
necessary. For all other psychiatric treatments LONG-TERM TREATMENT AND COMMUNITY
(except another rare treatment, hormone CARE Long-term treatment is often provided
implantation for reducing the sex drive of sex by GPs with support and guidance from psy-
offenders), either consent or a second opinion is chiatric teams. That is fine for people whose
needed not both. problems allow them to look after themselves,
TREATMENT IN HOSPITAL Psychiatric wards do and for those with plenty of support from fam-
not look like medical or surgical wards and staff ily and friends. But some people need much
may not wear uniforms. Patients do not need to more intensive long-term treatment and many
be in their beds during the day, so the beds are need help with running their daily lives.
in separate dormitories. The main part of most Since the 1950s, successive governments
wards is a living space with a day room, an have closed the old psychiatric hospitals and
activity and television room, quiet rooms, a din- have tried to provide as much care as possible
ing room, and a kitchen. Ward life usually has a outside hospital in the community. Com-
certain routine. The day often starts with a munity care is effective as long as everyone who
community meeting at which patients and needs inpatient care, or residential care, can
nurses discuss issues that affect the whole ward. have it. But demand exceeds supply. Research
Patients may go to the occupational therapy has shown that some homeless people have
department during the day, but there may also long-term mental illnesses and have somehow
be some therapy groups on the ward, such as lost touch with psychiatric services. Many more
relaxation training. Patients symptoms and have developed more general long-term health
problems are assessed continuously during a problems, particularly related to alcohol, with-
stay in hospital. When patients seem well out ever getting help.
enough they are allowed home for trial periods; The NHS and Community Care Act 1990,
M then discharge can be arranged. Patients are in force since 1993, established a new breed of
usually followed up in the outpatient clinic at professionals called care managers to assess
least once. people whose long-term illnesses and dis-
TREATING PATIENTS WITH ACUTE PSYCHIATRIC abilities make them unable to cope completely
ILLNESS Psychiatric emergencies patients independently with life. Care managers are
with acute psychiatric illness may develop given budgets by local councils to assess peoples
from psychological, physical, or practical crises. needs and to arrange for them tailor-made pack-
Any of these crises may need quick professional ages of care, including services like home helps
intervention. Relatives and friends often have to and day centres. But co-ordination between
get this urgent help because the sufferer is not health and social services has sometimes failed
fit enough to do it or, if psychotic, does not and resources are limited and the government
recognise the need. First, they should ring the decided in 1997 to tighten up arrangements and
persons general practitioner. If the general pool community-care budgets.
practitioner is not available and help is needed Since 1992 psychiatrists have had to ensure
very urgently, relatives or friends should phone that people with severe mental illnesses have full
the local social-services department and ask for programmes of care set up before discharge
the duty social worker (on 24-hour call). In a dire from hospital, to be overseen by named key
emergency, the police will know what to do. workers. And since 1996 psychiatrists have used
Any disturbed adult who threatens his or her a new power called Supervised Discharge to
own or others health and safety and refuses ensure that the most vulnerable patients cannot
psychiatric help may be moved and detained by lose touch with mental-health services. There is
law. The Mental Health Act of 1983 authorises not, however, any law that allows compulsory
emergency assessment and treatment of any treatment in the community.
person with apparent psychiatric problems that There is ample evidence that community
fulfil these criteria. care can work and that it need not cost more
Although admission to hospital may be the than hospital care. Critics argue, however, that
best solution, there are other ways that psychi- even one tragedy resulting from inadequate
atric services can respond to emergencies. In care, perhaps a suicide or even a homicide,
some districts there are crisis intervention should reverse the march to community care.
teams of psychiatrists, nurses, and social work- And, according to the National Schizophrenia
 Mercury 453

Fellowship, many of the 1015 homicides a seek additional help through school or the
year carried out by people with severe mental familys general practitioner. This may lead to
illnesses result from inadequate community the child and family being assessed and helped
care. by a psychologist, or, less commonly, by a child
Further information can be obtained from psychiatrist. Again, listening and counselling
the Mental Health Act Commission, and from will be the main forms of help offered. For out-
MIND, the National Association for Mental right depression, COGNITIVE BEHAVIOUR
Health. MIND also acts as a campaigning and THERAPY and, rarely, antidepressant drugs may
advice organisation on all aspects of mental be used.
health.
Mepacrine Hydrochloride
Mental health problems in children A synthetic acridine product used in the treat-
Emotional and behavioural problems are ment of MALARIA. It came to the fore during
common in children and adolescents, affecting World War II, when supplies of quinine were
up to one-fifth at any one time. But these prob- short, and proved of great value both as a
lems are often not clear-cut, and they may come prophylactic and in the treatment of malaria. It
and go as the child develops and meets new is now used only to treat infestation with
challenges in life. If a child or teenager has an tapeworms (see TAENIASIS).
emotional problem that persists for weeks
rather than days and is associated with dis- Meralgia Paraesthetica
turbed behaviour, he or she may have a recog- A condition characterised by pain and PAR-
nisable mental health disorder. AESTHESIA on the front and outer aspect of the
Anxiety, phobias and depression are fairly thigh. It is more common in men than in
common. For instance, surveys show that up to women, and the victims are usually middle-
2.5 per cent of children and 8 per cent of ado- aged, overweight and out of condition. It is due
lescents are depressed at any one time, and by to compression of the lateral cutaneous nerve of
the age of 18 a quarter will have been depressed the thigh, and exacerbated by an uncomfortable
at least once. Problems such as OBSESSIVE COM- driving position when motoring long distances.
PULSIVE DISORDER, ATTENTION DEFICIT DIS- Reduction in weight, improvement in general M
ORDER (HYPERACTIVITY SYNDROME), AUTISM, fitness and correction of faulty posture usually
ASPERGERS SYNDROME and SCHIZOPHRENIA are bring relief. If these fail, surgical decompression
rare. of the nerve may help.
Mental-health problems may not be obvious
at first, because children often express distress Mercaptopurine
through irritability, poor concentration, dif- One of the antimetabolite group of drugs (see
ficult behaviour, or physical symptoms. Phys- ANTIMETABOLITES), which includes methotrex-
ical symptoms of distress, such as unexplained ate, fluorouracil and thioguanine. These drugs
headache and stomach ache, may persuade par- are incorporated into new nuclear material in
ents to keep children at home on school days. the cell or combine irreversibly with vital cellu-
This may be appropriate occasionally, but regu- lar enzymes, preventing normal cellular metab-
larly avoiding school can lead to a persistent olism and division. Mercaptopurine is used
phobia called school refusal. mainly for the maintenance treatment of acute
If a parent, teacher or other person is wor- LEUKAEMIA, though it is increasingly proving
ried that a child or teenager may have a valuable in the treatment of CROHNS DISEASE.
mental-health problem, the first thing to do is As with all CYTOTOXIC drugs, dosage must be
to ask the child gently if he or she is worried carefully controlled; in particular it must be
about anything. Listening, reassuring and help- reduced if used concurrently with allopurinol.
ing the child to solve any specific problems Side-effects include gastrointestinal upsets
may well be enough to help the child feel (including ulceration), and bone-marrow
settled again. Serious problems such as bullying depression.
and child abuse need urgent professional
involvement. Mercury
Children with emotional problems will usu- Mercury is a heavy fluid metal which, with its
ally feel most comfortable talking to their par- salts, has been used in medicine for many
ents, while adolescents may prefer to talk to centuries.
friends, counsellors, or other mentors. If this
doesnt work, and if the symptoms persist for Uses In the past, mercuric salts were used
weeks rather than days, it may be necessary to as ANTISEPTICS, anti-parasitic agents and
 454 Mesalazine

fungicides. Mercury has been widely used in Mesoderm

dental amalgams for filling teeth. Because of The middle layer of the three germ layers of the
their toxicity, mercury compounds must not be EMBRYO during its early development. It
taken internally. develops into cartilage, bone, blood, muscle,
Mercury has traditionally been used in ther- kidneys, testes and connective tissue.
mometers for recording body temperature, and
in sphygmomanometers for measuring a per- Mesothelioma
sons BLOOD PRESSURE. These instruments have A malignant tumour of the PLEURA, the mem-
been largely replaced in the UK by electronic brane lining the chest cavity. The condition is
devices that do not require mercury. more common in people exposed to asbestos
dust. It may be asymptomatic or cause pain,
Mesalazine cough, and breathing troubles. Surgery or
An aminosalicylate drug used for the treatment radiotherapy may be effective but often the dis-
of mild to moderate ULCERATIVE COLITIS and ease has spread too far before it is discovered.
the maintenance of remission. It should be used Mesothelioma incurred as a result of contact
with caution by pregnant women. with asbestos at work may attract industrial
COMPENSATION.
Mescaline
Derived from the Mexican peyote cactus, Anha- Meta-Analysis
lonium lewinii, this is a hallucinogen used for A development of systematic reviews of ran-
many centuries by Indian tribes in Mexico as an domised, controlled trials in particular fields of
intoxicant to produce ecstatic states for health care. If this re-evaluation of the findings
religious celebrations. In recent times its ability of primary research also includes the aggrega-
to produce temporary psychotic symptoms has tion of data from all the re-evaluated studies
been used to investigate the mechanism of and a re-analysis of them, the procedure is
PSYCHOSIS. Mescaline has similar effects to described as meta-analysis. The technique has
those of LSD: changes in mood and thought, been used increasingly in medicine in recent
illusions, self-absorption and an altered percep- years, and the COCHRANE COLLABORATION has
M tion of time. Experience of the drug may been in the forefront of systematically reviewing
subsequently provoke panic attacks, deliberate and storing clinical and research data to provide
self-injury, real psychosis and sometimes a reliable information base on which to take
addiction (see DEPENDENCE). forward the practice of EVIDENCE-BASED MEDI-
CINE. Bias in medical research because, say, of
Mesencephalon an inadequately planned statistical base or only
The small section of brain stem excluding the small numbers in a trial is not uncommon,
pons and medulla linking the hindbrain to and meta-analysis of a group of broadly similar
the forebrain. (See BRAIN.) trials can provide more reliable data and reduce
the risk of erroneous conclusions.
Mesentery
Mesentery is the double layer of peritoneal Metabolic Disorders
membrane which supports the small INTES- A collection of disorders in which some part of
TINE. It is of a fan shape, and its shorter edge is the bodys internal chemistry (see METABOLISM;
attached to the back wall of the abdomen for a CATABOLISM) is disrupted. Some of these
distance of about 15 cm (6 inches), while the disorders arise from inherited deficiencies in
small intestine lies within its longer edge, for a which a specific ENZYME is absent or abnormal,
length of over 6 metres (20 feet). The terms or does not function properly. Other metabolic
mesocolon, mesorectum, etc., are applied to disorders occur because of malfunctions in the
similar folds of PERITONEUM that support parts endocrine system (see ENDOCRINE GLANDS).
of the colon, rectum, etc. There may be over- or underproduction of a
hormone involved in the control of metabolic
Mesmerism activities: a prime example is DIABETES MEL-
See HYPNOTISM. LITUS a disorder of sugar metabolism; others
include CUSHINGS SYNDROME; hypothyroid-
Mesocolon ism and hyperthyroidism (see THYROID GLAND,
The double fold of PERITONEUM by which the DISEASES OF); and insulinoma (an insulin-
large INTESTINE is suspended from the back producing tumour of the pancreas). The
wall of the abdomen. bones can be affected by metabolic disorders
such as osteoporosis, osteomalacia (rickets) and
 Meteorism 455

Pagets disease (see under BONE, DISORDERS OF). Metaphysis

PORPHYRIAS, HYPERLIPIDAEMIA, HYPERCAL- The extremity of a long bone where it joins the
CAEMIA and gout are other examples of dis- epiphysis (see BONE Growth of bones).
ordered metabolism.
There are also more than 200 identified Metaplasia
disorders described as inborn errors of meta- The term applied to a change of one kind of
bolism. Some cause few problems; others are tissue into another. Although not usually harm-
serious threats to an individuals life. Individual ful, it may be pre-cancerous if occurring in the
disorders are, fortunately, rare probably one cervix (neck of the womb or UTERUS), URINARY
child in 10,000 or 100,000; overall these BLADDER, or lining of the airways (bronchi).
inborn errors affect around one child in 1,000.
Examples include GALACTOSAEMIA, PHENYL- Metastasis
KETONURIA, porphyrias, TAY SACHS DISEASE Metastasis, and metastatic, are terms applied to
and varieties of mucopolysaccharidosis, the process by which malignant disease spreads
HOMOCYSTINURIA and hereditary fructose (a to distant parts of the body, and also to the
type of sugar) intolerance. secondary tumours resulting from this process.
For example, a cancer of the breast may pro-
Metabolism duce metastatic growths in the glands of the
This means tissue change, and includes all the armpit; cancer of the stomach may be followed
physical and chemical processes by which the by metastases in the liver. Metastases are col-
living body is maintained as well as those by loquially known as secondaries and their spread
which the energy is made available for various occurs through the bloodstream, lymphatic sys-
forms of work. The constructive, chemical and tem and across the body cavities. Highly malig-
physical, processes by which food materials are nant tumours for example, melanomas are
adapted for the use of the body are collectively especially prone to spread far and fast. (See
known as ANABOLISM. The destructive pro- CANCER.)
cesses by which energy is produced with the
breaking-down of tissues into waste products is Metastatic M
known as CATABOLISM. Basal metabolism is the See METASTASIS.
term applied to the energy changes necessary
for essential processes such as the beating of the Metatarsal Bones
heart, respiration, and maintenance of body The five bones in the foot which correspond to
warmth. This can be estimated, when a person the METACARPAL BONES in the hand, lying
is placed in a state of complete rest, by measur- between the tarsal bones, at the ankle, and the
ing the amounts of oxygen and carbon dioxide toes.
exchanged during breathing under certain
standard conditions. (See also CALORIE.) Metatarsalgia
Pain affecting the metatarsal region of the foot.
Metabolites It is common in adolescents, and associated
A biochemical compound that is involved in with FLAT-FOOT; in adults it may be a manifest-
the mechanism of the bodys METABOLISM. The ation of RHEUMATOID ARTHRITIS. Mortons
compounds are either produced during metab- metatarsalgia is a form associated usually with
olism or are in the food eaten by an individual. the nerve to the second toe cleft, often induced
by the compression of tight shoes.
Metacarpal Bones
The five long bones which occupy the HAND Metatarsus
between the carpal bones at the wrist and the Metatarsus is the group name of the five meta-
phalanges of the fingers. The large rounded tarsal bones in the foot. Metatarsus varus is the
knuckles at the root of the fingers are formed condition characterised by deviation of the fore-
by the heads of these bones. foot towards the other foot. It is a common
condition in newborn babes and almost always
Metamyelocyte corrects itself spontaneously. Only in the rare
An immature granulocyte (white blood cell) cases in which it is due to some deformity of the
usually found in the bone marrows blood- bones or muscles of the foot is any treatment
making tissue. It can, however, appear in the required.
blood in a range of diseases, including
infection. Meteorism
Also known as tympanites, this is a distension
 456 Metformin

of theABDOMEN from excess gas or air in the toxic form. The latter is caused by certain
INTESTINE or peritoneal cavity. On percussion drugs, including acetanilide, phenacetin, the
the abdomen sounds resonant, like a drum. sulphonamides and benzocaine. The treatment
Causes include obstruction of the intestines, of the toxic form is the withdrawal of the causa-
aerophagy (the swallowing of air), and IRRIT- tive drug. In the more severe cases the adminis-
ABLE BOWEL SYNDROME (IBS). Treatment is tration of methylene blue or ascorbic acid may
of the underlying condition. (See also also be needed, and these are the drugs used in
FLATULENCE.) the hereditary form.

Metformin Methane
One of the BIGUANIDES, metformin lowers the An odourless, colourless, highly flammable gas.
blood sugar by increasing cellular uptake of glu- It occurs naturally in gas from coal mines and
cose. It is active when taken by mouth and is oil wells, where it is a hazard because of its
used to treat some patients with DIABETES explosive properties. Natural gas supplied to
MELLITUS, usually in addition to another homes and industries is almost 100 per cent
hypoglycaemic drug. methane. Unlike coal gas, it is not poisonous
unless present in large amounts, when it may
Methadone Hydrochloride displace oxygen and thus asphyxiate (suffocate)
Also known as Physeptone, this is a synthetic anyone exposed to it. Decomposition of
drug structurally similar to MORPHINE, one of organic matter produces methane.
many opioid drugs used to treat severe pain.
Methadone is, however, less sedating and has a Methanol
longer half-life. Furthermore, it is more reliable A variety of ALCOHOL used as a solvent to
when taken orally. Although vomiting is com- remove paint or as a constituent of some anti-
mon, this is generally less severe than with freeze fluids. It is poisonous: sometimes people
morphine. drink it as a substitute for ethyl (ordinary) alco-
Methadone is valuable as a suppressant for hol. Symptoms appear up to 24 hours after
non-productive cough, acting on the medullary imbibing methanol and include nausea, vomit-
M cough centre in the central nervous system. It ing, dizziness, headache and sometimes
is also helpful in weaning addicts off morphine unconsciousness. Treatment is to induce vomit-
and heroin, having a slower onset of DEPEND- ing (in conscious victims) and to do a stomach
ENCE and a less severe withdrawal syndrome. washout (see GASTRIC LAVAGE), but such steps
When used for prolonged periods, methadone must be taken within two hours of ingestion.
should not be given more often than twice Hospital treatment is usually required, when
daily, to avoid the risks of accumulation and intravenous infusion of sodium bicarbonate
opioid overdosage. (and sometimes ethanol, which slows up
breakdown of methanol by the liver) is
Methaemoglobin administered.
A derivative of HAEMOGLOBIN in which the
iron has been oxidised from ferrous to ferric Methicillin-Resistant
form. It does not combine with oxygen and Staphylococcus Aureus (MRSA)
therefore plays no part in oxygen transport. Most staphylococci (see STAPHYLOCOCCUS)
Normal concentration of methaemoglobin in have now evolved resistance to benzylpenicillin
red blood cells is less than 1 per cent of the total (see PENICILLIN) because of their ability to pro-
haemoglobin. When a large concentration of duce PENICILLINASE. Cloxacillin and flucloxa-
the haemoglobin is in the form of methaemo- cillin are antibiotics still effective against most
globin, the patient will suffer from HYPOXIA staphylococci; at one time methicillin was used
and will be cyanosed (see CYANOSIS). Most cases to combat resistant strains, but in hospital
of METHAEMOGLOBINAEMIA are due to chem- environments bacteria acquired immunity to
ical agents. this powerful drug (now withdrawn from use)
and to cloxacillin. RIFAMPICIN, VANCOMYCIN,
Methaemoglobinaemia TEICOPLANIN and temocillin are still active
Methaemoglobinaemia is a condition due to against most penicillinase-producing gram-
the presence in the blood of METHAEMO- negative bacteria (see GRAMS STAIN). There is,
GLOBIN. It is characterised by CYANOSIS which however, a growing threat to health because of
turns the skin and lips a blue colour, shortness the rise in the number of antibiotic-resistant
of breath, headache, fatigue and sickness. There bacteria, particularly in hospitals. The bacteria
are two main forms: a hereditary form and a themselves are not more virulent than others,
 Methylphenidate 457

but the difficulty in treating them with a safe Methyl

and effective antibiotic mean that they are more Methyl is an organic radical whose chemical
dangerous. It is likely that lapses in normal formula is CH3, and which forms the centre of
hygienic practice such as frequent hand- a wide group of substances known as the methyl
washing has resulted in an increase in MRSA group. For example, methyl alcohol is obtained
disease. as a by-product in the manufacture of beet-
sugar, or by distillation of wood; methyl
Methionine salicylate is the active constituent in oil of
Methionine is an essential amino acid (see wintergreen; methyl hydride is better known as
AMINO ACIDS; INDISPENSABLE AMINO ACIDS) marsh gas.
that contains sulphur; it is necessary for normal Methyl alcohol, or wood spirit (see METHA-
growth in infants and to maintain nitrogen NOL), is distilled from wood and is thus a cheap
balance in adults. form of alcohol. It has actions similar to, but
much more toxic than, those of ethyl alcohol. It
Methotrexate has a specially pronounced action on the ner-
One of the ANTIMETABOLITES used to treat cer- vous system, and in large doses is apt to cause
tain forms of malignant disease. Acting to neuritis, especially of the optic nerves, leading
inhibit the ENZYME dihydrofolate reductase, to blindness, partial or complete.
which is essential for purine and pyrimidine
synthesis, it is given orally, intravenously, Methylbenzene
intramuscularly or intrathecally. Methotrexate See TOLUENE.
is used as maintenance therapy for childhood
acute lymphoblastic LEUKAEMIA, while other Methylcellulose
uses include CHORIOCARCINOMA, non- A COLLOID which absorbs water to swell to
Hodgkins LYMPHOMA, and various solid about 25 times its original volume. It is used in
tumours. Intrathecally, it is used in the the treatment of CONSTIPATION and also in the
prophylaxis of childhood acute lymphoblastic management of OBESITY. The rationale for its
leukaemia, and as treatment for established use in obesity is that by swelling up in the stom-
meningeal cancer or lymphoma. M
ach, it reduces the appetite.
Side-effects include suppression of myelo-
cytes in bone marrow, inflammation of mucous Methyldopa
membranes, and, rarely, PNEUMONITIS. It A centrally acting anti-hypertensive (see HYPER-
should be avoided whenever significant renal TENSION) drug often used in conjunction with
impairment is present, while significant pleural a diuretic (see DIURETICS). It can be effective in
effusion or ascites is also a contraindication. controlling high blood pressure in pregnancy.
Blood counts should be carefully monitored The drug is also safe to use in patients with
whenever intrathecal methotrexate is given. ASTHMA or heart failure.
Oral or parenteral folinic acid helps to prevent,
or to speed recovery from, myelosuppression or Methylene Blue
mucositis. Methylene blue, or methylthionin chloride, is
Methotrexate is used in dermatology, where used in a dose of 75100 mg, as a 1-per-cent
it may be indicated for cases of severe intravenous injection, in the treatment of
uncontrolled PSORIASIS unresponsive to con- METHAEMOGLOBINAEMIA, which may occur
ventional therapy; it may also be indicated for following high doses of local anaesthetics such
severe active RHEUMATOID ARTHRITIS. Because as prilocaine.
of its potentially severe haematological, pul-
monary, gastrointestinal, and other toxicities it Methylphenidate
should be used only by specialists and appropri- A drug that stimulates the CENTRAL NERVOUS
ate renal and liver function tests carried out SYSTEM. Its action is similar to DEXAMPHETA-
before and during treatment. It should be MINE. A controlled drug, one of its trade names
avoided in pregnancy, and conception should is Ritalin and it is (controversially) used in the
be avoided for at least six months after stop- treatment of ATTENTION DEFICIT DISORDER
ping, as should breast feeding. Concurrent (HYPERACTIVITY SYNDROME) in children, in
administration of aspirin or other NON- conjunction with behavioural treatment and
STEROIDAL ANTI-INFLAMMATORY DRUGS family support. Because of the potential for
(NSAIDS) reduces methotrexate excretion, side-effects, its administration should be under
increasing its toxicity, and should therefore be specialist supervision.
avoided whenever possible.
 458 Methylprednisolone

Methylprednisolone national System of Units (SI). It is equivalent to

A mineralcorticoid drug (see CORTICO- 3937 inches.
STEROIDS) with an action comparable to that of
PREDNISOLONE, but effective at a somewhat Metritis
lower dose. Inflammation of the uterus (see UTERUS, DIS-
EASES OF).
Methyl Salicylate
Also called oil of Wintergreen, the liquid has Metronidazole
analgesic (see ANALGESICS) and counter-irritant An antimicrobial drug particularly active
properties. Rubbed into the skin, the oil helps against anaerobic (see ANAEROBE) bacteria and
to relieve pain in LUMBAGO, SCIATICA and PROTOZOA. Given by mouth, by rectum or
rheumatic conditions. intravenously, it is used to treat infections of the
urinary, genital, and digestive systems for
Methysergide example, TRICHOMONIASIS, amoebiasis (see
A drug used to prevent attacks of MIGRAINE. DYSENTERY), GIARDIASIS, and acute ulcerative
The drug requires hospital supervision, as it GINGIVITIS, and is a useful treatment for dental
has to be used with care because of the toxic abscesses. Topically, it is used in the manage-
effects it sometimes produces for example, ment of ROSACEA and it reduces the odour pro-
nausea, drowsiness and retroperitoneal duced by anaerobic bacteria in fungating
FIBROSIS. tumours.
It may cause a DISULFIRAM-like reaction with
Metoclopramide alcohol; caution is similarly indicated in
This drug antagonises the actions of DOPA- patients with impaired liver function or hepatic
MINE. Given orally, intramuscularly, or intra- encephalopathy, and who are pregnant or breast
venously, it is used to treat nausea and feeding. Rare side-effects include nausea, vomit-
vomiting, particularly in gastrointestinal dis- ing, unpleasant taste, furred tongue and gastro-
orders, or when associated with cytotoxics or intestinal disturbances; rashes, URTICARIA, and
radiotherapy. It is useful in the early treatment angio-oedema (see under URTICARIA); drowsiness,
M of MIGRAINE. headache, dizziness, ATAXIA and ANAPHYLAXIS.
Caution is indicated in prescribing metoclo-
pramide for elderly and young patients, and Metropathia Haemorrhagica
whenever hepatic or renal impairment is pres- A disorder characterised by irregular bouts of
ent, and it should be avoided in pregnancy or uterine (see UTERUS) bleeding without previ-
cases of PORPHYRIAS. Adverse effects include ous OVULATION due to excessive oestrogenic
extrapyramidal effects (see under EXTRAPYRAMI- activity. It is associated with endometrial
DAL SYSTEM) and HYPERPROLACTINAEMIA with hyperplasia and cysts of the ovary.
occasional TARDIVE DYSKINESIA on prolonged
administration. There have also been occasional Metrorrhagia
reports of drowsiness, restlessness, diarrhoea, Uterine (see UTERUS) bleeding otherwise than at
depression and neuroleptic malignant syn- the proper period (see MENSTRUATION). It is
drome, with rare cardiac conduction abnormal- usually due to a uterine lesion and should be
ities following intravenous administration. investigated.

Metolazone Metyrapone
A thiazide-type diuretic (see THIAZIDES; Metyrapone is a drug that inhibits the produc-
DIURETICS) which is particularly effective when tion of CORTISOL in the adrenal cortex, which
combined with a loop diuretic (see LOOP results in an increase in ACTH production and
DIURETICS), when it produces profound (completing the feedback control cycle) thus
diuresis. The drug is also useful for treating greater synthesis of the chemical precursors of
kidney stones (see under KIDNEYS, DISEASES OF). cortisol. Metyrapone is used to treat patients
with CUSHINGS SYNDROME (a condition caused
Metoprolol by excess amounts of corticosteroid hormones
A beta-adrenergic-receptor blocking agent. (See in the body) where surgery is not possible.
ADRENERGIC RECEPTORS.)
Miconazole
Metre One of the IMIDAZOLES group of antifungals
The basic unit of length in the modern version which includes clotrimazole and ketoconazole.
of the metric system, known as the Inter- Active against a wide range of fungi and yeasts,
 Microbiology 459

their main indications are vaginal candidiasis their small size and absence of a cell wall
and dermatophyte skin infections. Miconazole (mycoplasma) or major wall component (chla-
is used as a cream or ointment; it may also be mydia), are now acknowledged as bacteria;
given orally (for oral or gastrointestinal infec- rickettsiae and chlamydia are intracellular para-
tions), or parenterally (for systemic infections sites of medical importance. Bacteria may also
such as aspergillosis or candidiasis). (See possess additional surface structures, such as
MYCOSIS.) capsules and organs of locomotion (flagella)
and attachment (fimbriae and stalks). Indi-
Microangiopathy vidual bacterial cells may be spheres (cocci);
Disease of the CAPILLARIES. straight (bacilli), curved (vibrio), or flexuous
(spirilla) rods; or oval cells (coccobacilli). On
Microbe examination by light microscopy, bacteria may
See BACTERIA; MICROBIOLOGY. be visible in characteristic configurations (as
pairs of cocci [diplococci], or chains [strepto-
Microbicides cocci], or clusters); actinomycete bacteria grow
Gels or creams, currently under investigation, as filaments with externally produced spores.
designed to reduce the risk of anal or vaginal Bacteria grow essentially by increasing in cell
transmission of viruses such as HIV (see also AIDS/ size and dividing by fission, a process which in
HIV). The aim is to kill or to inactivate the ideal laboratory conditions some bacteria may
virus, creating a barrier to mucosal cells or pre- achieve about once every 20 minutes. Under
venting the infection from taking hold after it natural conditions, growth is usually much
has entered the body. Large-scale trials were slower.
launched in Africa in 2004, using dextrin Eukaryotic micro-organisms comprise fungi,
sulphate and PRO-2000 gel. algae, and protozoa. These organisms are larger,
and they have in common a well-developed
Microbiology internal compartmentation into subcellular
The study of all aspects of micro-organisms organelles; they also have a nucleus. Algae add-
(microbes) that is, organisms which individu- itionally have chloroplasts, which contain
ally are generally too small to be visible other photosynthetic pigments; fungi lack chloro- M
than by microscopy. The term is applicable to plasts; and protozoa lack both a cell wall and
viruses (see VIRUS), BACTERIA, and microscopic chloroplasts but may have a contractile vacuole
forms of fungi, algae, and PROTOZOA. to regulate water uptake and, in some, struc-
Among the smallest and simplest micro- tures for capturing and ingesting food. Fungi
organisms are the viruses. First described as fil- grow either as discrete cells (yeasts), multiplying
terable agents, and ranging in size from 2030 by budding, fission, or conjugation, or as thin
nm to 300 nm, they may be directly visualised filaments (hyphae) which bear spores, although
only by electron microscopy. They consist of a some may show both morphological forms
core of deoxyribonucleic or ribonucleic acid during their life-cycle. Algae and protozoa gen-
(DNA or RNA) within a protective protein coat, erally grow as individual cells or colonies of
or capsid, whose subunits confer a geometric individuals and multiply by fission.
symmetry. Thus viruses are usually cubical (ico- Micro-organisms of medical importance
sahedral) or helical; the larger viruses (pox-, include representatives of the five major
herpes-, myxo-viruses) may also have an outer microbial groups that obtain their essential
envelope. Their minimal structure dictates that nutrients at the expense of their hosts. Many
viruses are all obligate parasites, relying on liv- bacteria and most fungi, however, are sapro-
ing cells to provide essential components for phytes (see SAPROPHYTE), being major contribu-
their replication. Apart from animal and plant tors to the natural cycling of carbon in the
cells, viruses may infect and replicate in bacteria environment and to biodeterioration; others are
(bacteriophages) or fungi (mycophages), which of ecological and economic importance because
are damaged in the process. of the diseases they cause in agricultural or
Bacteria are larger (0015,000 m) and horticultural crops or because of their beneficial
more complex. They have a subcellular organ- relationships with higher organisms. Addition-
isation which generally includes DNA and ally, they may be of industrial or biotechnologi-
RNA, a cell membrane, organelles such as ribo- cal importance. Fungal diseases of humans tend
somes, and a complex and chemically variable to be most important in tropical environments
cell envelope but, unlike EUKARYOTES, no and in immuno-compromised subjects.
nucleus. Rickettsiae, chlamydia, and myco- Pathogenic (that is, disease-causing) micro-
plasmas, once thought of as viruses because of organisms have special characteristics, or
 460 Microcephaly

virulence factors, that enable them to colonise Microcyte

their hosts and overcome or evade physical, A small red blood cell.
biochemical, and immunological host defences.
For example, the presence of capsules, as in the Microdissection
bacteria that cause anthrax (Bacillus anthracis), The technique of dissecting very small struc-
one form of pneumonia (Streptococcus pneumo- tures under a microscope. Miniature surgical
niae), scarlet fever (S. pyogenes), bacterial men- instruments are manipulated via geared connec-
ingitis (Neisseria meningitidis, Haemophilus tions that convert the coarse movements of the
influenzae) is directly related to the ability to surgeons fingers into miniscule movements,
cause disease because of their antiphagocytic making it possible to dissect and separate even
properties. Fimbriae are related to virulence, individual CHROMOSOMES.
enabling tissue attachment for example, in
gonorrhoea (N. gonorrhoeae) and cholera (Vib- Microfilaria
rio cholerae). Many bacteria excrete extracellular The mobile embryo of certain parasitic nema-
virulence factors; these include enzymes and tode worms which are found in the blood or
other agents that impair the hosts physiological lymph of patients infected with filarial worms.
and immunological functions. Some bacteria The microfilariae develop into larvae in the
produce powerful toxins (excreted exotoxins or body of a blood-sucking insect, for example, a
endogenous endotoxins), which may cause local mosquito.
tissue destruction and allow colonisation by the
pathogen or whose specific action may explain Microgram
the disease mechanism. In Staphylococcus Microgram is the 1/1,000th part of a milligram.
aureus, exfoliative toxin produces the staphylo- The abreviation for it is g. (See APPENDIX 6:
coccal scalded-skin syndrome, TSS toxin-1 MEASUREMENTS IN MEDICINE.)
toxic-shock syndrome, and enterotoxin food
poisoning. The pertussis exotoxin of Bordetella Micrometre
pertussis, the cause of whooping cough, blocks The 1/1,000th part of a millimetre. The
immunological defences and mediates attach- abbreviation for it is m. (See APPENDIX 6:
M ment to tracheal cells, and the exotoxin pro- MEASUREMENTS IN MEDICINE.)
duced by Corynebacterium diphtheriae causes
local damage resulting in a pronounced exudate Micro-Organism
in the trachea. A very small, single-celled living organism that
Viruses cause disease by cellular destruction cannot usually be seen by the naked eye. The
arising from their intracellular parasitic exist- most important micro-organisms in medicine
ence. Attachment to particular cells is often are those that cause disease. This pathogenic
mediated by specific viral surface proteins; group, however, forms only a small proportion
mechanisms for evading immunological of the enormous number of known micro-
defences include latency, change in viral anti- organisms. The main pathogenic ones are BAC-
genic structure, or incapacitation of the TERIA. Others are fungi and RICKETTSIA.
immune system for example, destruction of Though not true cells, viruses (see VIRUS) are
CD 4 lymphocytes by the human immuno- usually classified as micro-organisms. (See also
deficiency virus. MICROBIOLOGY.)

Microcephaly Micropsia
Abnormal smallness of the head, usually associ- Condition in which objects appear smaller than
ated with LEARNING DISABILITY. It may occur normal. It can be due to disease of the macula
as a result of infection of the fetus by, for of the EYE.
example, RUBELLA (German measles) or from
hypoxic damage to the brain before or during Microscope
birth. An optical instrument comprising adjustable
magnifying lenses that greatly enlarge a small
Micrococcus object under study for example, an insect,
A spherical gram-positive bacterium (see BAC- blood cells, or bacteria. Some microscopes use
TERIA; GRAMS STAIN). It occurs in colonies and electron beams to magnify minute objects such
is usually harmless in humans. However, micro- as chromosomes, crystals, or even large mol-
coccus can become pathogenic and cause ecules. Optical microscopes are also used for
abscesses (see ABSCESS), ARTHRITIS, ENDOCARD- MICROSURGERY when the area being operated
ITIS or MENINGITIS. on is otherwise inaccessible: for example, in eye
 Migraine 461

and inner ear surgery; for the removal of Mid-Life Crisis

tumours from the brain or spinal cord; and for A colloquial description of the feelings of anx-
resuturing damaged blood vessels and nerves. iety and distress experienced by some indi-
viduals in early middle age. They realise that by
Microsporum 45 years of age they are no longer young, and
One of the three genera of dermatophytes men in particular try to turn the clock back by
(fungi) which cause tinea (see RINGWORM). changing jobs, dressing trendily, taking up
Microsporum of human or animal origin is an energetic or unusual sports or engaging in
important cause of tinea capitis, or ringworm of extramarital liaisons. Sometimes those in mid-
the scalp. life crises develop mild or even serious DEPRES-
SION. The feelings of anxiety and insecurity
Microsurgery usually disappear with time but some people
The conduct of very intricate surgical oper- may benefit from counselling.
ations using specially refined operating micro-
scopes (see MICROSCOPE) and miniaturised Midwife
precision instruments for example, forceps, A member of the profession which provides
scalpels, scissors, etc. Microsurgery is used in care and advice during pregnancy, supervises
previously inaccessible areas of the brain, eye, the mothers labour and delivery, and looks
inner ear and spinal cord, as well as in the after her and the baby after birth (see also PREG-
suturing of severed nerves and small blood ves- NANCY AND LABOUR). Should a pregnancy or
sels following traumatic injuries to the limbs or labour develop complications, the midwife will
fingers. The technique is also used to reverse seek medical advice. Most midwives are regis-
VASECTOMY. tered general nurses who have also done an 18-
month course in midwifery. Trained midwives
Microtome are registered with the UK Central Council for
A laboratory instrument for cutting sections of Nursing Midwifery and Health Visiting and
biological tissues for study under a MICRO- work in hospitals or a domiciliary setting.
SCOPE. It is widely used in biological and Midwives practise in hospitals, health units or
PATHOLOGY laboratories. in a domiciliary (home) setting.
M

Microwaves Midwifery
Non-ionising electro-magnetic radiations in the See MIDWIFE; PREGNANCY AND LABOUR.
frequency range of 30300,000 megahertz.
They are emitted from electronic devices, such Migraine
as heaters, some domestic ovens, television The word migraine derives from HEMICRANIA,
receivers, radar units and DIATHERMY units. the Greek for half a skull, and is a common
There is no scientific evidence to justify the condition characterised by recurring intense
claims that they are harmful to humans, or that headaches. It is much more usual in women
they produce any harmful effect in the GENES. than in men and affects around 10 per cent of
The only known necessary precaution is the the population. It has been defined as episodic
protection of the eyes in those using them in headache accompanied by visual or gastrointest-
industry, as there is some evidence that pro- inal disturbances, or both, attacks lasting hours
longed exposure to them in this may induce with total freedom between episodes.
cataract (see EYE, DISORDERS OF). It usually begins at puberty although young
children can be affected and tends to stop in
Micturition middle age: in women, for example, attacks
The act of URINATION (see also URINARY BLAD- often cease after MENOPAUSE. It frequently dis-
DER; URINE). appears during pregnancy. The disorder tends
to run in families. In susceptible individuals,
Middle Ear attacks may be provoked by a wide variety of
That portion of the EAR lying between the causes including: anxiety, emotion, depression,
TYMPANIC MEMBRANE and the INNER EAR. It shock, and excitement; physical and mental
contains the ossicles, the three small bones that fatigue; prolonged focusing on computer, tele-
transmit sound. vision or cinema screens; noise, especially loud
and high-pitched sounds; certain foods such
Midges as chocolate, cheese, citrus fruits, pastry; alco-
See BITES AND STINGS. hol; prolonged lack of food; irregular meals;
menstruation and the pre-menstrual period.
 462 Milia

Anything that can provoke a headache in the sickness. The less food that is taken during an
ordinary individual can probably precipitate an attack the better, provided that the individual
attack in a migrainous subject. It seems as if drinks as much fluid as he or she wants. Group
there is an inherited predispostion that triggers therapy, in which groups of around ten
a mechanism whereby in the migrainous sub- migrainous subjects learn how to relax, is often
ject, the headache and the associated sickness of help in more severe cases, whilst in others the
persist for hours, a whole day or even longer. injection of a local anaesthetic into tender spots
The precise cause is not known, but the gen- in the scalp reduces the number of attacks.
erally accepted view is that in susceptible indi- Drug treatment can be effective and those
viduals, one or other of these causes produces afflicted by migraine may find a particular drug
spasm or constriction of the blood vessels of the or combination of drugs more suitable than
brain. This in turn is followed by dilatation of others. ANALGESICS such as PARACETAMOL,
these blood vessels which also become more aspirin and CODEINE phosphate sometimes
permeable and so allow fluid to pass out into help. A combination of buclizine hydrochloride
the surrounding tissues. This combination of and analgesics, taken when the visual aura
dilatation and outpouring of fluid is held to be occurs, prevents or diminishes the severity of an
responsible for the headache. attack in some people. A commonly used rem-
Two types of migraine have been recognised: edy for the condition is ergotamine tartrate,
classical and common. The former is relatively which causes the dilated blood vessels to
rare and the headache is preceded by a slowly contract, but this must only be taken under
extending area of blindness in one or both eyes, medical supervision. In many cases METOCLO-
usually accompanied by intermittent lights. PRAMIDE (an antiemetic), followed ten minutes
The phenomenon lasts for up to 30 minutes later by three tablets of either aspirin or para-
and is followed by a bad, often unilateral head- cetamol, is effective if taken early in an attack.
ache with nausea, sometimes vomiting and In milder attacks, aspirin, with or without
sensitivity to light. Occasionally, passing neuro- codeine and paracetamol, may be of value.
logical symptoms such as weakness in a limb SUMATRIPTAN (5-hydroxytryptamine [5HT1]
may accompany the attack. The common var- AGONIST also known as a SEROTONIN agonist)
M iety has similar but less severe symptoms. It is of value for acute attacks. It is used orally or
consists of an intense headache, usually situated by subcutaneous injection, but should not be
over one or other eye. The headache is usually used for patients with ischaemic heart disease.
preceded by a feeling of sickness and disturb- Naratriptan is another 5HT1 agonist that is an
ance of sight. In 1520 per cent of cases this effective treatment for acute attacks; others
disturbance of sight takes the form of bright are almotriptan, rizariptan and zolmitriptan.
lights: the so-called AURA of migraine. The Some patients find beta blockers such as
majority of attacks are accompanied by vomit- propranolol a valuable prophylactic.
ing. The duration of the headache varies, but in People with migraine and their relatives can
the more severe cases the victim is usually con- obtain help and guidance from the Migraine
fined to bed for 24 hours. Action Association.

Treatment consists, in the first place, of try- Milia

ing to avoid any precipitating factor. Patients These are small keratin cysts appearing as white
must find out which drug, or drugs, give them papules on the cheek and eyelids.
most relief, and they must always carry these
about with them wherever they go. This is Miliaria
because it is a not uncommon experience to be Also known as prickly heat. An intensely itchy
aware of an attack coming on and to find that vesicular and erythematous rash induced by
there is a critical quarter of an hour or so during intense heat and humidity. It is caused by a
which the tablets are effective. If not taken disturbance of sweat-gland function.
within this period, they may be ineffective and
the unfortunate victim finds him or herself Miliary
prostrate with headache and vomiting. In add- A term, expressing size, applied to various dis-
ition, sufferers should immediately lie down; at ease products which are about the size of millet
this stage a few hours rest may prevent the seeds: for example, miliary aneurysms, miliary
development of a full attack. tuberculosis.
When an attack is fully developed, rest in bed
in a quiet, darkened room is essential; any loud Milium
noise or bright light intensifies the headache or Milium is a pinhead white cyst of the skin of
 Minimally Invasive Surgery (MIS) 463

the face containing corneal cells. It can be Dried milk is prepared by evaporating all the
removed on the point of a sterile needle. fluid so that the milk is reduced to the form of
powder. Humanised milk is cows milk treated
Milk to render it closely similar to human milk.
The natural food of all mammalia for a con-
siderable period following their birth. It is prac- Milk Teeth
tically the only form of animal food in which The temporary teeth of children. (For the time
protein, fat, carbohydrate and salt are all repre- of their appearance, see under TEETH.)
sented in sufficient amount, and it therefore
contains all the constituents of a standard diet. Millilitre
Milk is important in human nutrition because Millilitre is the 1,000th part of 1 litre. It is prac-
it contains first-class animal protein of high bio- tically the equivalent of a cubic centimetre
logical value; because it is exceptionally rich in (1 cm3 = 0999973 ml); ml is the usual
calcium; and because it is a good source of abbreviation.
vitamin A, thiamine and riboflavine. It also
contains a variable amount of ascorbic acid Mind
(vitamin C) and of vitamin D the amount of (1) The seat of consciousness of the human
the latter being higher during the summer BRAIN. The mind understands, reasons and ini-
months than during the winter months. Raw tiates action and is also the source of emotions.
milk yields 67 Calories (see CALORIE) per 100 This is a simplistic definition for a concept that
millilitres, in which are present (in grams) 876 has been and continues to be the subject of vig-
of water, 33 of protein, 36 of fat, 47 of carbo- orous debate among theologians, philosophers,
hydrate, and 012 of calcium. Heat has no effect biologists, psychologists, psychiatrists and other
on the vitamin A or D content of milk, or on doctors, their arguments being too complex for
the riboflavine content, but it causes a consider- inclusion in a dictionarys definition.
able reduction in the vitamin C and thiamine (2) MIND: The National Association for Men-
content. tal Health, a voluntary charitable body that
works in the interests of those with MENTAL
Preparation of milk Milk may be pre- ILLNESS, advising, educating and campaigning
M
pared for food in various ways. Boiling destroys for and supporting them.
the bacteria, especially any Mycobacteria tuber-
culosis which the milk may contain. It also Mineralcorticoid
partly destroys vitamin C and thiamine, as does See CORTICOSTEROIDS.
pasteurisation. Curdling of milk is effected by
adding rennet, which carries out the initial Minim
stage of digestion and thus renders milk more A pre-metric unit of measurement of volume.
suitable for people who could not otherwise It is about one-60th part of a fluid drachm and
tolerate it. Souring of milk is practised in many is used in pharmacy.
countries before milk is considered suitable for
food; it is carried out by adding certain organ- Minimum Lethal Dose (MLD)
isms such as the LACTIC ACID bacillus, the Bul- See MLD.
garian bacillus, and setting the milk in a warm
place for several hours. Sterilisation, which pre- Minimally Invasive Surgery
vents fermentation and decomposition, is usu- (MIS)
ally carried out by raising the milk to boiling More popularly called keyhole surgery, MIS is
temperature (100 C) for 15 minutes and surgical intervention, whether diagnostic or
then hermetically sealing it. Condensed, curative, that causes patients the least possible
unsweetened milk usually known as evapor- physical trauma. It has revolutionised surgery,
ated milk is concentrated in vacuo at low growing from a technique used by gynae-
temperature; the milk is then placed in tins, cologists, urologists and innovative general sur-
which are sealed, and is sterilised by heat at a geons to one regularly used in general surgery,
temperature of 105 C. This destroys 60 per GYNAECOLOGY, UROLOGY, thoracic surgery,
cent of the vitamin C and 3050 per cent of the orthopaedic surgery (see ORTHOPAEDICS) and
thiamine. Sweetened condensed milk is not OTORHINOLARYNGOLOGY.
exposed to such a high temperature. The sugar, MIS is commonly carried out by means of an
which prevents the growth of micro-organisms, operating laparoscope (a type of ENDOSCOPE)
is added before the condensing, and finally that is slipped through a small incision in the
reaches a concentration of about 40 per cent. skin. MIS now accounts for around 50 per cent
 464 Minocycline

Removal of stones from gall-bladder using the technique of minimally invasive surgery.

of all operations carried out in the UK. A small

M attachment on the end of the laparoscope pro- Minocycline
One of the tetracycline broad-spectrum anti-
vides an image that can be magnified on a biotic drugs (see TETRACYCLINES). Minocycline
screen, leaving the surgeons hands free to oper- has a broader spectrum than the others and is
ate while his assistant operates the laparoscope. effective against Neisseria meningitidis, which
Halogen bulbs, fibreoptic cables and rod lenses causes bacterial MENINGITIS. It should not be
have all contributed to the technical advance- prescribed for patients with kidney disease.
ment of laparoscopes. Operations done in this
manner include extracorporeal shock-wave Minoxidil
LITHOTRIPSY for stones in the gall-bladder, A vasodilator drug taken orally to treat people
biliary ducts and urinary system; removal of with serious HYPERTENSION. Minoxidil is also
the gall-bladder; appendicectomy; removal of used as a lotion to treat male-pattern baldness
the spleen and adrenal glands; and thoracic (in both sexes). The drug can cause fluid reten-
sympathectomy. MIS is also used to remove tion, weight gain and excessive growth of the
cartilage or loose pieces of bone in the knee- hair.
joint.
This method of surgery usually means that Miosis
patients can be treated on a day or overnight Condition of constriction (reduction in size) of
basis, allowing them to resume normal activ- the pupil (see EYE). It may be the result of dis-
ities more quickly than with conventional sur- ease affecting the AUTONOMIC NERVOUS SYS-
gery. It is safer and lessens the trauma and TEM. Bright light causes miosis and some drugs
shock for patients needing surgery. MIS is also for example, PILOCARPINE or OPIUM have
more cost effective, allowing hospitals to treat the same effect.
more patients in a year. Surgeons undertake
special training in the use of MIS, a highly Miscarriage
skilled technique, before they are permitted to See ABORTION.
use the procedures on patients. The use of MIS
for hernia repair, colon surgery and repairs of Misoprostol
duodenal perforations is under evaluation and A PROSTAGLANDIN analogue used to treat duo-
its advantages will be enhanced by the devel- denal and gastric ulcers, and those induced by
opment of robotic surgical techniques. NON-STEROIDAL ANTI-INFLAMMATORY DRUGS
 Mitral Incompetence 465

(NSAIDS). It should not be taken by pregnant or accepted medical uses: amphetamines,

breast-feeding women. cocaine.
III: Lower potential for abuse: barbiturates,
Misuse of Drugs meprobamate, temazepam.
See also MEDICINES. Government legislation IV: Lower potential for abuse than I to III.
covers the manufacture, sale and prescription of Minimal control: benzodiazepines.
drugs in the UK. As well as stating which drugs
may be sold over the counter (OTC) without a
V: Low potential for abuse: generally com-
pound preparations containing small
doctors or dentists prescription, and those amounts of opioids: kaolin and morphine
which can be obtained only with such a pre- (antidiarrhoeal medicine), codeine linctus
scription, government regulations determine (cough suppressant).
the extent of availability of many substances (See also CONTROLLED DRUGS.)
which are liable to be abused see Misuse of
Drugs Act 1971 (below). The Misuse of Drugs Mites
Regulations 1985 define those individuals who A mite is an arthropod belonging to a group of
in their professional capacity are authorised to insects called ACARINA. It may be parasitic or
supply and possess controlled drugs: see the free-living. Most mites are less than 1 mm long
schedules of drugs listed below under the 1985 and medically significant ones include those
regulations. that cause DERMATITIS (dermatophagoides) and
the harvest mite, which transmits scrub typhus
Misuse of Drugs Act 1971 This legisla- (see under TYPHUS FEVER).
tion forbids activities relating to the manu-
facture, sale and possession of particular Mitochondria
(controlled) drugs. These are classified into The rod-like bodies in the CELLS of the body
three grades according to their dangers if mis- which contain the enzymes (see ENZYME) neces-
used. Any offences concerning class A drugs, sary for the activity of the cell. They have been
potentially the most damaging when abused, described as the power plant of the cell
carry the toughest penalties, while classes B and
C attract lesser penalties if abused. Mitosis M
Class A includes: cocaine, dextromoramide,
diamorphine (heroin), lysergic acid (LSD),
The process of cell division for somatic cells and
for the ovum after fertilisation. Each chromo-
methadone, morphine, opium, pethidine, some becomes doubled by splitting lengthwise
phencyclidine acid and injectable prepar- and forming two chromatids which remain
ations of class B drugs. held together by the centromere. These chro-
Class B includes: oral amphetamines, barbit-
urates, codeine, glutethimide, marijuana
matids are exact copies of the original chromo-
somes and contain duplicates of all the genes
(cannabis), pentazocine and pholcodine. they bear. When cell division takes place, the
Class C includes: drugs related to the
amphetamines, anabolic and androgenic
pull of the spindle splits the centromere and
each double chromatid separates, one passing to
steroids, many benzodiazepines, buprenor- one pole of the nucleus and the other to the
phine, diethyl propion, human chorionic opposite pole. The nucleus and the cell itself
gonadotrophin (HCG), mazindol, mep- then also divide, forming two new daughter
robamate, pemoline, phenbuterol, and cells containing precisely the same 23 pairs of
somatropin. chromosomes and carrying exactly the same
complement of genes as did the mother cell. (See
Misuse of Drugs Regulations CHROMOSOMES; FERTILISATION; GENES;
1985 These regulations define those people HEREDITY.)
who are authorised in their professional cap-
acity to supply and possess controlled drugs. Mitral Incompetence
They also describe the requirements for legally A defect in the MITRAL VALVE of the HEART
undertaking these activities, such as storage of which allows blood to leak from the left VEN-
the drugs and limits on their prescription. TRICLE into the left ATRIUM. It is also known as
Drugs are divided into five schedules and mitral regurgitation; incompetence may occur
some examples follow. along with MITRAL STENOSIS. The left ventricle
I: Almost all are prohibited except in accord-
ance with Home Office authority: marijuana
has to work harder to compensate for the faulty
valve, so it enlarges, but eventually the ventricle
(cannabis), LSD. cannot cope with the extra load and left-sided
II: High potential for abuse but have heart failure may develop. A common cause of
 466 Mitral Stenosis

mitral incompetence is RHEUMATIC FEVER or several countries have failed to find any
damage following a heart attack. The condition evidence to back the claim. Nonetheless, the
is treated with drugs to help the heart, but in publicity war has been largely lost by the UK
severe cases heart surgery may be required. health departments so that vaccine rates have
dropped to a worryingly low level.
Mitral Stenosis (See IMMUNISATION.)
Narrowing of the opening between the left
ATRIUM and left VENTRICLE of the HEART as a MND
result of rigidity of, and adhesion between, the See MOTOR NEURONE DISEASE (MND).
cusps of the MITRAL VALVE. It is due, almost
invariably, to the infection RHEUMATIC FEVER. Moclobemide
The atrium has to work harder to force blood A reversible monoamine oxidase inhibitor (see
through the narrowed channel. The effects are MONOAMINE OXIDASE INHIBITORS (MAOIS)),
similar to those of MITRAL INCOMPETENCE. this drug is used as second-line treatment for
Shortness of breath and palpitations and irregu- patients with severe DEPRESSION. As with all
lar beating (fibrillation) of the atrium are com- MAOIs, those taking moclobemide should
mon consequences in adults. Drug treatment avoid too much tyramine-rich food mature
with DIGOXIN and DIURETICS helps, but sur- cheese, yeast extracts, fermented soya-bean
gery to dilate or replace the faulty valve may be products and they should not take the drug
necessary. with another antidepressant (see ANTIDEPRES-
SANT DRUGS).
Mitral Valve
The mitral valve, so-called because of its resem- Mode
blance to a bishops mitre, is the valve which A statistical term which is the most frequently
guards the opening between the ATRIUM and occurring value of a set of observations. If the
VENTRICLE on the left side of the HEART. results are plotted as a graph, the mode is the
peak of the curve which results.
MLD
M The minimal lethal dose or smallest amount of Molar Teeth
a toxic compound needed to cause death. The last three TEETH on each side of the JAW.

MMR Vaccine Mole

A combined vaccine offering protection against (1) A term used to describe the common pig-
MEASLES, MUMPS and RUBELLA (German mea- mented spots which occur on human SKIN. It
sles), it was introduced in the UK in 1988 and arises from a collection of abnormal melano-
has now replaced the measles vaccine. The cytes (see MELANOCYTE) in the dermis adjacent
combined vaccine is offered to all infants in to the epidermodermal junction. Moles are
their second year; health authorities have an usually not present at birth, and appear in
obligation to ensure that all children have childhood or adolescence. Most moles are less
received the vaccine by school entry it should than 5 mm in diameter and are macular at first,
be given with the pre-school booster doses becoming raised later. Rarely, moles are present
against DIPHTHERIA, TETANUS and POLIOMYEL- at birth and may occasionally be massive. There
ITIS, if not earlier unless there is a valid is a substantial risk of future malignancy (see
contra-indication (such as partial immunosup- MALIGNANT) in massive congenital moles and
pression), parental refusal, or evidence of pre- prophylactic surgical removal is advised if feas-
vious infection. MMR vaccine may also be ible. All humans have moles, but their number
used in the control of measles outbreaks, if varies from ten or fewer to 100 or more. The
offered to susceptible children within three members of some families are genetically pre-
days of exposure to infection. The vaccine is disposed to large numbers of moles, some of
effective and generally safe, though minor which may be large and irregular in shape and
symptoms such as malaise, fever and rash may colour. This atypical mole syndrome is associ-
occur 510 days after immunisation. The inci- ated with an increased risk of future malignant
dence of all three diseases has dropped substan- MELANOMA.
tially since MMR was introduced in the UK (2) An internationally agreed unit (see SI UNITS)
and USA. for measuring the quantity of a substance at
A researcher has suggested a link between the molecular level.
vaccine and AUTISM, but massive studies of
children with and without this condition in
 Monocyte 467

Molecular Biology Monoamine Oxidase Inhibitors

The study of molecules (see MOLECULE) that are (MAOIs)
part of the structure of living organisms. These are drugs that destroy, or prevent the
action of, monoamine oxidase (MAO).
Molecule Monoamines, which include NORADRENALINE
The smallest possible amount of a substance and tyramine, play an important part in the
comprising two or more linked atoms which metabolism of the BRAIN, and there is some
retains the chemical characteristics of that sub- evidence that excitement is due to an accumula-
stance. Molecules vary greatly in their size and tion of monoamines in the brain. MAO is a
complexity, ranging from oxygen (two linked naturally occurring ENZYME which is concerned
oxygen atoms) and water (two hydrogen atoms in the breakdown of monoamines. MAOIs were
and one oxygen) to large complex molecules among the earliest ANTIDEPRESSANT DRUGS
such as deoxyribonucleic acid (DNA) compris- used, but they are now used much less than
ing thousands of atoms of carbon, hydrogen, tricyclic and related antidepressants, or SELECT-
oxygen, nitrogen and phosphorus that form the IVE SEROTONIN-REUPTAKE INHIBITORS (SSRIS)
double-helix structure which helps to form and related antidepressants, because of the dan-
GENES, the basic building blocks of the heredi- gers of dietary or drug interactions and
tary material of living things. because MAOIs are less effective than these two
groups.
Molluscum Contagiosum An excessive accumulation of monoamines
Common papular eruption of the skin caused can induce a dangerous reaction characterised
by a virus. Most common in children, it is by high blood pressure, palpitations, sweating
highly contagious and often transmitted in and a feeling of suffocation. Hence the care
swimming pools and sauna baths. Mollusca are with which MAOI drugs are administered.
often multiple and persistent in children with What is equally important, however, is that in
atopic eczema (see DERMATITIS), and epidemics no circumstances should a patient receiving any
may occur in boarding schools. The typical MAOI drug eat cheese, yeast preparations such
molluscum is 23 mm in diameter, skin- as Marmite, tinned fish, or high game. The rea-
coloured and translucent, with a dimpled
M
son for this ban is that all these foodstuffs con-
centre. The armpits and adjacent chest, upper tain large amounts of tyramine which increases
inner thighs and genital areas are common sites the amount of certain monoamines such as
in young children. In adults the infection is noradrenaline in the body. (See MENTAL
usually transmitted sexually and affects the ILLNESS.)
pubic area and lower belly. Mollusca eventually There are also certain drugs, such as
disappear spontaneously, but cure can be exped- AMPHETAMINES and PETHIDINE HYDRO-
ited by curettage (removal with a CURETTE) CHLORIDE, which must not be taken by a
under surface anaesthesia. patient who is receiving an MAOI drug. The
MAOIs of choice are phenelzine or isocarbox-
Mongolian Blue Spots azid because their stimulant effects are less than
Irregularly shaped areas of bluish-black pigmen- those of other MAOIs, making them safer.
tation found occasionally on the buttocks,
lower back or upper arms in newborn infants of Monoclonal Antibodies
African, Chinese and Japanese parentage, and An artificially prepared antibody (see ANTI-
sometimes in the babies of black-haired Euro- BODIES) obtained from cell clones a genetic-
peans. They measure from one to several ally identical group of cells and comprising a
centimetres in diameter, and usually disappear single type of immunoglobulin. It neutralises
in a few months. They are commonly mistaken only one specific ANTIGEN. The antibodies are
for bruises. prepared by linking antibody-forming lympho-
cytes (see LYMPHOCYTE) from the spleen of mice
Mongolism with myeloma cells from mice. Monoclonal
See DOWNS (DOWN) SYNDROME. antibodies are used in the development of new
vaccines and in the study of human cells, hor-
Moniliasis mones, and micro-organisms. Research is under
The infection caused by monilia, the genus of way for their use in the treatment of some forms
fungi now known as Candida albicans (see CAN- of cancer. (See IMMUNOLOGY.)
DIDA). The infection may occur in the mouth
where it is known as thrush lungs, intestine, Monocyte
vagina, skin, or nails. A type of white blood cell which has a single
 468 Monomania

kidney-shaped nucleus. Present in the tissues EPSTEIN BARR VIRUS, which causes
and lymphatic system as well as in the circula- MONONUCLEOSIS.
tion, it ingests foreign particles such as tissue
debris and bacteria. Monocytes are about 20 Monozygotic Twins
m in diameter and 1 mm3 of blood contains Twins who develop from a single OVUM fertil-
around 7,500 of them, many times fewer than ised by a single SPERMATOZOON. Also known as
the five million erythrocytes (red blood cells). identical or uniovular twins (see MULTIPLE
BIRTHS).
Monomania
Monomania is a form of MENTAL ILLNESS, in Morbid Anatomy
which the affected person has delusion (see The study of the structural changes that diseases
DELUSIONS) upon one subject, although he or cause in the body, in particular those which can
she can converse rationally and is a responsible be seen with the naked eye at POST-MORTEM
individual upon other matters. EXAMINATION.

Mononucleosis Morbidity
An acute viral infection in which the patient The condition of being diseased. The morbid-
developes a sore throat, swollen lymph glands ity rate is the number of cases of disease occur-
and fever. Also known as glandular fever, infec- ring within a particular number of the
tious mononucleosis is caused by members of population.
the herpes group of viruses the EPSTEIN BARR
VIRUS and CYTOMEGALOVIRUS (CMV). The dis- Morbilli
ease is more common among adolescents aged Another name for MEASLES.
1517, an age when their immune defence
mechanisms are not fully developed. In the UK Morbus
many thousands of teenagers catch the disease Morbus, the Latin word for disease, is used in
every year, and kissing is believed to be the such terms as morbus cordis (heart disease),
method of transmission among many of them. morbus coxae (hip-joint disease).
M The blood contains many atypical lymphocytes
(see LYMPHOCYTE) and the diagnosis is con- Moribund
firmed with the heterophil antibodies test. In a state of dying.
Patients normally recover within six weeks
without treatment, but they may feel tired and Morning-After Pill
depressed for several months afterwards. Some See CONTRACEPTION.
cases of MYALGIC ENCEPHALOMYELITIS (ME)
and other chronic fatigue syndromes occur after Moron
infection with this virus. An out-of-date term previously used to describe
individuals with mild learning difficulties, but
Monoplegia which is now offensive.
PARALYSIS of a single limb or part.
Moro Reflex
Monorchism A primitive REFLEX ACTION occurring in newly
The absence of one testis, usually the result of born infants in response to a sudden movement
the failure of one TESTICLE to drop down into or noise. Also known as the startle reflex, the
the SCROTUM before birth. Monorchism is baby will throw its arms and legs wide and
sometimes used to describe the condition when stiffen its body. This is followed by flexion of
one testicle has been destroyed by disease or the arms and legs. The reflex disappears by four
injury, or has been surgically removed when, months; its persistence suggests a possible
for example, the man has developed cancer of neurological condition such as CEREBRAL PALSY.
the testicle.
Morphine
Monosaccharide Morphine is the name of the chief alkaloid (see
A sugar having six carbon atoms in the mol- ALKALOIDS) upon which the action of OPIUM
ecule, such as glucose, galactose, and laevulose. depends. A traditional and invaluable opioid
analgesic (see ANALGESICS) used to control
Monospot severe pain, it is the standard against which
A screening test, performed on blood, which other opioid analgesics are measured. Used
indicates the likelihood of infection with widely in patients with post-operative pain or
 Motor Neurone Disease (MND) 469

those in PALLIATIVE care who have severe pain, Depression, giddiness, nausea and vomiting are
it produces a sense of EUPHORIA. A serious side- the most prominent.
effect is that morphine can cause nausea and
vomiting. The drug may also cause DEPEND- Causes Although the vast majority of people
ENCE. Morphine is a Class A controlled drug appear to be liable to this ailment at sea, they do
and is classifed in Schedule II of the Misuse of not all suffer alike. Many endure acute distress,
Drugs Regulations 1985 (see CONTROLLED whilst others are simply conscious of transient
DRUGS; MEDICINES; MISUSE OF DRUGS). feelings of nausea and discomfort. A smaller
proportion of people suffer from air and car
Morphoea sickness. The symptoms are a result of over-
A form of circumscribed SCLERODERMA. stimulation of the organs of balance in the
inner EAR by continuous changes in the bodys
Mortality position. The movements of the horizon
See DEATH, CAUSES OF; DEATH RATE; INFANT worsen this situation.
MORTALITY RATE (IMR).
Symptoms The symptoms generally show
Mortification themselves soon after the journey has started,
Mortification is another name for GANGRENE. by the onset of giddiness and discomfort in the
head, together with a sense of nausea and sink-
Mosaicism ing at the stomach, which soon develops into
If non-dysjunction occurs after the formation intense sickness and vomiting. Most people
of a ZYGOTE that is, during a mitotic cell recover quickly when the motion stops.
division and not a meiotic cell division (see
MITOSIS; MEIOSIS) some of the cells will have Treatment Innumerable preventives and
one chromosome constitution and others remedies have been proposed. Cinnarizine 30
another. The term mosaicism describes a condi- mg orally is useful 2 hours before travel, then
tion in which a substantial minority of cells in 15 mg every 8 hours during the journey if
an individuals body differ from the majority in necessary. Dimenhydrinate and promethazine
their chromosome content. How substantial are also commonly taken for motion sickness. M
this minority is will depend upon how early
during cleavage the zygote undergoes non- Motor
dysjunction. Mosaicism can cause disorders A term usually applied to nerves, used to
such as DOWNS (DOWN) SYNDROME and describe anything that results in movement.
TURNERS SYNDROME. The proportion and Motor nerves stimulate muscles to contract,
type of abnormal cells affect the physical producing movement. (See also SENSORY.)
appearance of the affected individual. This may
range from normal to the features typical of Motor Neurone Disease (MND)
people with a chromosomal-abnormality A group of disorders of unknown origin. Cer-
syndrome. tain cells in the neurological systems MOTOR
nerves degenerate and die. Upper and lower
Mosquitoes motor neurones may be affected but sensory
See ANOPHELES; BITES AND STINGS; MALARIA. cells retain their normal functions. Three types
of MND are identified: amyotrophic lateral
Motilin sclerosis (AML 50 per cent of patients); pro-
Motilin is a hormone (see HORMONES) formed gressive muscular atrophy (25 per cent), in
in the DUODENUM and the JEJUNUM which which the prognosis is better than for AML;
plays a part in controlling the movements of the and bulbar palsy (25 per cent). Men are affected
stomach and the gut. more than women, and the disorder affects
about seven people in every 100,000. Those
Motion affected develop progressive weakness and wast-
Waste products evacuated in a bowel move- ing of their muscles. The diagnosis is confirmed
ment, also called faeces or stool. with various tests including the measurement of
electrical activity in muscles, electromyography,
Motion (Travel) Sickness muscle BIOPSY, blood tests and X-ray examin-
A characteristic set of symptoms experienced by ation of the spine. There is no medical treat-
many people when subjected to the constant ment: patients need physical and psychological
changes of position caused, for example, by the support with aids to help them overcome
pitching and rolling motion of a vessel at sea. disabilities. The Motor Neurone Disease
 470 Mountain Sickness

Association provides excellent advice and help ring. They may be associated with STRESS or
for sufferers and their relatives. (See APPENDIX 2: DYSPEPSIA. There is no ideal treatment.
ADDRESSES: SOURCES OF INFORMATION, Herpetic ulcers (see HERPES SIMPLEX) are
ADVICE, SUPPORT AND SELF-HELP.) similar but usually there are many ulcers and
the patient appears feverish and unwell. This
Mountain Sickness condition is more common in children.
See ALTITUDE SICKNESS.
Calculus (a) Salivary: a calculus (stone) may
Mouth, Diseases of develop in one of the major salivary-gland
The mucous membrane of the mouth can indi- ducts. This may result in a blockage which will
cate the health of the individual and internal cause the gland to swell and be painful. It usu-
organs. For example, pallor or pigmentation ally swells before a meal and then slowly sub-
may indicate ANAEMIA, JAUNDICE or ADDISONS sides. The stone may be passed but often has to
DISEASE. be removed in a minor operation. If the gland
behind the calculus becomes infected, then an
Thrush is characterised by the presence of ABSCESS forms and, if this persists, the removal
white patches on the mucous membrane which of the gland may be indicated. (b) Dental, also
bleeds if the patch is gently removed. It is called TARTAR: this is a calcified material which
caused by the growth of a parasitic mould adheres to the teeth; it often starts as the soft
known as Candida albicans. Antifungal agents debris found on teeth which have not been well
usually suppress the growth of candida. Candi- cleaned and is called plaque. If not removed, it
dal infiltration of the mucosa is often found in will gradually destroy the periodontal mem-
cancerous lesions. brane and result in the loss of the tooth. (See
TEETH, DISORDERS OF.)
Leukoplakia literally means a white patch.
In the mouth it is often due to an area of Ranula This is a cyst-like swelling found in
thickened cells from the horny layer of the the floor of the mouth. It is often caused by
epithelium. It appears as a white patch of mild trauma to the salivary glands with the
M varying density and is often grooved by dense result that saliva collects in the cyst instead of
fissures. There are many causes, most of them discharging into the mouth. Surgery may be
of minor importance. It may be associated required.
with smoking, SYPHILIS, chronic SEPSIS or
trauma from a sharp tooth. Cancer must be Mumps is an acute infective disorder of the
excluded. major salivary glands. It causes painful
enlargement of the glands which lasts for about
Stomatitis (inflammation of the mouth) two weeks. (See also main entry for MUMPS.)
arises from the same causes as inflammation
elsewhere, but among the main causes are the Tumours may occur in all parts of the
cutting of teeth in children, sharp or broken mouth, and may be BENIGN or MALIGNANT.
teeth, excess alcohol, tobacco smoking and gen- Benign tumours are common and may follow
eral ill-health. The mucous membrane becomes mild trauma or be an exaggerated response to
red, swollen and tender and ulcers may appear. irritation. Polyps are found in the cheeks and
Treatment consists mainly of preventing sec- on the tongue and become a nuisance as they
ondary infection supervening before the stoma- may be bitten frequently. They are easily
titis has resolved. Antiseptic mouthwashes are excised.
usually sufficient. A MUCOCOELE is found mainly in the lower
lip.
Gingivitis (see TEETH, DISEASES OF) is An exostosis or bone outgrowth is often
inflammation of the gum where it touches the found in the mid line of the palate and on the
tooth. It is caused by poor oral hygiene and is inside of the mandible (bone of the lower jaw).
often associated with the production of calculus This only requires removal if it becomes unduly
or tartar on the teeth. If it is neglected it will large or pointed and easily ulcerated.
proceed to periodontal disease. Malignant tumours within the mouth are
often large before they are noticed, whereas
Ulcers of the mouth These are usually those on the lips are usually seen early and are
small and arise from a variety of causes. Aph- more easily treated. The cancer may arise
thous ulcers are the most common; they last from any of the tissues found in the mouth
about ten days and usually heal without scar- including epithelium, bone, salivary tissue and
 Mucus 471

tooth-forming tissue remnants. Oral cancers therefore form wherever there is mucous
represent about 5 per cent of all reported membrane.
malignancies, and in England and Wales
around 3,300 people are diagnosed annually as Mucocutaneous Lymph Node
having cancer of the mouth and PHARYNX. Syndrome
Cancer of the mouth is less common below See KAWASAKI DISEASE.
the age of 40 years and is more common in
men. It is often associated with chronic irrita- Mucolytic
tion from a broken tooth or ill-fitting denture. The term used to describe the property of des-
It is also more common in those who smoke troying, or lessening the tenacity of, MUCUS. It
and those who chew betel leaves. Leukoplakia is most commonly used to describe drugs which
(see above) may be a precursor of cancer. Spread have this property and are therefore used in the
of the cancer is by way of the lymph nodes in treatment of BRONCHITIS. The inhalation of
the neck. Early treatment by surgery, radio- steam, for example, has a mucolytic action.
therapy or chemotherapy will often be effective,
except for the posterior of the tongue where the Mucopolysaccaridhosis
prognosis is very poor. Although surgery may A collection of familial metabolic disorders, the
be extensive and potentially mutilating, recent best known of which is Hurlers syndrome (see
advances in repairing defects and grafting tis- GARGOYLISM). Others include Hunters,
sues from elsewhere have made treatment more Maroteaux-Lamy and Scheies syndromes. The
acceptable to the patient. disorders, which result from a faulty gene-
producing abnormality in a specific ENZYME,
Mouth-To-Mouth Respiration affect one child in 10,000. Those affected
See APPENDIX 1: BASIC FIRST AID. usually die before reaching adulthood.

MRI Mucosa
MRI, or magnetic resonance imaging, is a non- A term for MUCOUS MEMBRANE.
invasive method of imaging the body and its
organs. It may also be used to study tissue Mucous Membrane M
metabolism. The body is placed in a magnetic The general name given to the membrane
field which causes certain atomic nuclei to which lines many of the hollow organs of the
align in the direction of the field. Pulses of body. These membranes vary widely in struc-
radio-frequency radiation are then applied; ture in different sites, but all have the common
interpretation of the frequencies absorbed and character of being lubricated by MUCUS
re-emitted allows an image in any body plane to derived in some cases from isolated cells on the
be built up. Different tissues for example, fat surface of the membrane, but more generally
and water can be separately identified and, if from definite glands placed beneath the mem-
the resonance signal for the fat is suppressed, brane, and opening here and there through it by
then only the signal from any abnormalities in ducts. The air passages, the gastrointestinal
the fat can be identified. Many diseases result in tract and the ducts of glands which open into it,
a rise in the water content of tissues,so MRI is a and also the urinary passages, are all lined by
valuable test for identifying disease, and the mucous membrane.
operating radiologist is skilled in interpreting
the meaning of altered signals. Mucoviscidosis
See CYSTIC FIBROSIS.
MRSA
See METHICILLIN-RESISTANT STAPHYLOCOCCUS Mucus
AUREUS (MRSA). The general name for the slimy secretion
derived from mucous membranes. It is mainly
Mucilage composed of a substance called mucin, which
This is prepared from acacia or tragacanth gum, varies according to the particular mucous
and is used as an ingredient of mixtures con- membrane from which it is derived, and it con-
taining solid particles in order to keep the latter tains other substances, such as cells cast off from
from settling, and also as a demulcent. the surface of the membrane, enzymes, and
dust particles. Mucin has the following charac-
Mucocoele teristics: it is viscid, clear and tenacious; when
An abnormally dilated cavity in the body due to dissolved in water it can be precipitated by add-
the accumulation of MUCUS; such a cyst may ition of acetic acid; and when not in solution
 472 Mullerian Ducts

already, it is dissolved by weak alkalis, such as developed from a single ovum fertilised by a single
lime-water. spermatozoon, but which has split early in devel-
Under normal conditions the surface of a opment. This is why they are usually so remark-
mucous membrane is lubricated by only a small ably alike in looks and mental characteristics.
quantity of mucus; the appearance of large Unlike binovular twins, who may be of the same
quantities is a sign of inflammation. or different sex, they are always of the same sex.
So far as fraternal, or binovular, twins are
Mullerian Ducts concerned, multiple pregnancy may be an
The Mullerian and the Wolffian ducts are sep- inherited tendency; it certainly occurs more
arate sets of primordia that transiently co-exist often in certain families, but this may be partly
in embryos of both sexes (see EMBRYO). In due to chance. A woman who has already given
female embryos the Mullerian ducts grow and birth to twins is ten times more likely to have
fuse in the mid line, producing the FALLOPIAN another multiple pregnancy than one who has
TUBES, the UTERUS and the upper third of the not previously had twins. The statistical chance
VAGINA, whereas the Wolffian ducts regress. In of a third pair of twins is 1:512,000. Identical
the male the Wolffian ducts give rise to the VAS twins do not run in families.
DEFERENS, the seminal vesicles and the EPI- The relative proportion of twins of each type
DIDYMIS, and the Mullerian ducts disappear. varies in different races. Identical twins have
This phase of development requires a function- much the same frequency all over the world:
ing testis (see TESTICLE) from which an inducer around 3 per 1,000 maternities. Fraternal twins
substance diffuses locally over the primordia to are rare in Mongolian races: less than 3 per
bring about the suppression of the Mullerian 1,000 maternities. In Caucasians they occur
duct and the development of the Wolffian duct. two or three times as often as identical twins:
In the absence of this substance, development between 7 (Spain and Portugal) and 10 (Czech
proceeds along female lines regardless of the and Slovak Republics and Greece) per 1,000
genetic sex. maternities. They are more common in Afro-
Caribbeans, reaching 30 per 1,000 maternities
Multigravida in certain West African populations.
M A pregnant woman who has had more than one Rarely, uniovular twins may not develop as
pregnancy. separate individuals, being physically joined in
some way. They are called conjoined or (trad-
Multipara itionally) Siamese twins. Depending on the
A woman who has borne several children. extent of common structures shared by the
infants this ranges from a common umbilical
Multiple Births cord to twins with conjoined heads or a com-
Twins occur about once in 80 pregnancies, trip- mon liver the infants may be successfully sep-
lets once in 6,000, and quadruplets about once arated by surgery. (See CONJOINED TWINS.)
in 500,000. Quintuplets are exceedingly rare. Parents of twins, triplets, etc. can obtain
Such is the natural state of affairs. advice and help from the Twins and Multiple
In recent years, however, the position has Births Association (TAMBA).
been altered by the introduction of the so-called
fertility drugs, such as CLOMIPHENE, and Multiple Personality Disorder
human menopausal gonadotrophin which, The individual with this psychiatric disorder
through the medium of the PITUITARY GLAND, has two or more different personalities, often
stimulate the production of ova (see OVUM). contrasting. The dominant personality at the
Their wide use in the treatment of INFERTILITY time determines the behaviour and attitude of
has resulted in an increase in the number of the individual, who customarily seems not to
multiple births, a recognised hazard of giving know about the other personality or person-
too large a dose. alities. The switch from one personality to
Twins may be binovular or uniovular. Bino- another is abrupt and the mental condition of
vular, or fraternal, twins are the result of the the differing personalities is usually normal. It is
mothers releasing two ova within a few days of possible that child abuse is a factor in the dis-
each other and both being fertilised by separate order, which is treated by psychotherapy. The
spermatozoa (see SPERMATOZOON). They both classic multiple personality was the fictional
develop separately in the mothers womb and form of Dr Jekyll and Mr Hyde.
are no more alike than is usual with members of
the same family. They are three times as com- Multiple Sclerosis (MS)
mon as uniovular, or identical, twins, who are Multiple sclerosis is a progressive disease of the
 Mumps 473

BRAIN and SPINAL CORD, which, although slow particularly in the early stages of the disease. As
in its onset, in time may produce marked symp- the disease progresses, the paralyses, which were
toms such as PARALYSIS and tremors (see transitory at first, now become confirmed, often
TREMOR), and may ultimately result in a with great rigidity in the limbs. In many
severely disabled invalid. The disorder consists patients the disease progresses very slowly.
of hardened patches, from the size of a pin-head People with multiple sclerosis, and their rela-
to that of a pea or larger, scattered here and tives, can obtain help and guidance from the
there irregularly through the brain and spinal Multiple Sclerosis Society. Another helpful
cord. Each patch is made up of a mass of the organisation is the Multiple Sclerosis Resources
CONNECTIVE TISSUE (neuroglia), which should Centre. Those with sexual or marital problems
be present only in sufficient amount to bind the arising out of the illness can obtain information
nerve-cells and fibres together. In the earliest from SPOD (Association to Aid the Sexual and
stage, the insulating sheaths (MYELIN) of the Personal Relationships of People with a Dis-
nerve-fibres in the hardened patches break up, ability). (See APPENDIX 2: ADDRESSES: SOURCES
are absorbed, and leave the nerve-fibres bare, OF INFORMATION, ADVICE, SUPPORT AND SELF-
the connective tissue being later formed HELP.)
between these.
Treatment is difficult, because the most that
Cause Although this is one of the most com- can be done is to lead a life as free from strain as
mon diseases of the central nervous system in possible, to check the progress of the disease.
Europe there are around 50,000 affected The use of INTERFERON beta seems to slow the
individuals in Britain alone the cause is still progress of MS and this drug is licensed for use
not known. The disease comes on in young in the UK for patients with relapsing, remitting
people (onset being rare after the age of 40), MS over two years, provided they can walk
apparently without previous illness. The ratio unaided a controversial restriction on this
of women-to-men victims is 3:2. It is more (expensive) treatment. CORTICOSTEROIDS may
common in first and second children than in be of help to some patients.
those later in birth order, and in small rather The NATIONAL INSTITUTE FOR CLINICAL
than big families. There may be a hereditary EXCELLENCE (NICE) ruled in 2001 that the use
M
factor for MS, which could be an autoimmune of the drugs interferon beta and glatiramer
disorder: the bodys defence system attacks the acetate for patients with multiple sclerosis was
myelin in the central nervous system as if it not cost-effective but recommended that the
were a foreign tissue. Department of Health, the National Assembly
for Wales and the drug manufacturers should
Symptoms These depend greatly upon the consider ways of making the drugs available in a
part of the brain and cord affected by the scler- cost-effective way. Subsequently the govern-
otic patches. Temporary paralysis of a limb, or ment said that it would consider funding a
of an eye muscle, causing double vision, and risk-sharing scheme in which supply of drugs
tremors upon exertion, first in the affected to patients would be funded only if treatment
parts, and later in all parts of the body, are early trials in individuals with MS showed that they
symptoms. Stiffness of the lower limbs causing were effective.
the toes to catch on small irregularities in the The Department of Health has asked NICE
ground and trip the person in walking, is often to assess two CANNABIS derivatives as possible
an annoying symptom and one of the first to be treatments for multiple sclerosis and the relief
noticed. Great activity is shown in the reflex of post-operative pain. Trials of an under-the-
movements obtained by striking the tendons tongue spray and a tablet could, if successsful,
and by stroking the soles of the feet. The latter lead to the two drugs being available around
reflex shows a characteristic sign (Babinski sign) 2005.
in which the great toe bends upwards and the It is important to keep the nerves and
other toes spread apart as the sole is stroked, muscles functioning, and therefore the patient
instead of the toes collectively bending down- should remain at work as long as he or she is
wards as in the normal person. Tremor of the capable of doing it, and in any case should exer-
eye movements (nystagmus) is usually found. cise regularly.
Trembling handwriting, interference with the
functions of the bladder, giddiness, and a pecu- Mumps
liar staccato or scanning speech are common Mumps, also known as epidemic parotitis, is an
symptoms at a later stage. Numbness and infectious disease characterised by inflamma-
tingling in the extremities occur commonly, tory swelling of the PAROTID GLAND and other
 474 Munchausens Syndrome

SALIVARY GLANDS often occurring as an EPI- pitals with symptoms and signs (often simu-
DEMIC and affecting mostly young people. Its lated) suggestive of serious physical illness.
name comes from the old verb, mump, mean- More common among men than women, it dif-
ing to mope or assume a disconsolate appear- fers from MALINGERING in that no obvious
ance an apt description of the victim of the reward results from the imagined or simulated
disease at its height. symptoms. Patients may simulate signs and
symptoms in a bizarre way for instance, by
Causes Mumps is due to infection with a swallowing blood or inserting needles into the
virus and is highly infectious from person to chest. Abdominal symptoms are particularly
person. It is predominantly a disease of child- common. They often have a history of multiple
hood and early adult life, but it can occur at any hospital admissions and operations, and show
age. Epidemics usually occur in the winter and extensive pathological lying and lack of per-
spring. It is infectious for two or three days sonal rapport. Although the cause is unclear, it
before the swelling of the glands appears. A vac- is thought to be a form of hysterical behaviour
cine is now available that gives a high degree of in a severely disordered personality. Patients
protection against the disease, the incidence of are often masochistic, attention-seeking, and
which is falling sharply. The vaccine is com- constantly trying to obtain ANALGESICS.
bined with those for MEASLES and RUBELLA see Occasionally there may be a degree of treatable
MMR VACCINE; IMMUNISATION. DEPRESSION, but on the whole management is
very difficult as patients often abscond from
Symptoms There is an incubation period of psychiatric treatment.
23 weeks after infection before the glands A variation of the syndrome Munchausens
begin to swell. The gland first affected is gener- syndrome by proxy, better termed fabricated
ally the parotid, situated in front of and below and induced illness has been identified, in
the ear. The swelling usually spreads to the which the persons affected inflict damage upon
submaxillary and sublingual glands lying others, usually children (or even animals) in
beneath the jaw. The patient is feverish and the their care. Factitious illness refers to simulating
gland is tender. The swelling disappears after symptoms, such as stating that the child has
M about five days. In 1530 per cent of males, blood in its urine when it is actually the parents
inflammation of the testicles (orchitis) blood. Induced illness includes such events as
develops. This usually occurs during the second injecting dirty water into a babys muscles,
week of the illness, but may not occur until 23 dropping mild caustic into their eyes, adding
weeks later; it may result in partial ATROPHY of salt to a babys milk or diluting it 5050 with
the testicles, but practically never in INFERTIL- water, and so on. Much debate has ensued
ITY. In a much smaller proportion of females about the suggestion that some sudden infant
with mumps, inflammation of the OVARIES or deaths are due to smothering rather than nat-
BREASTS may occur. Inflammation of the PAN- ural causes, as a type of induced illness. As a
CREAS, accompanied by tenderness in the upper consequence of two successful appeals against
part of the abdomen and digestive disturbances, conviction for murder in 2004, the UK attor-
sometimes results, and MENINGITIS is also an ney general ordered a review of all criminal and
occasional complication. The various complica- family court cases in which disputed medical
tions are found much more often when the evidence had formed the basis of the decision.
disease affects adults than when it occurs in Paediatricians are concerned that one result is
childhood. likely to be an increase in undetected child
abuse.
Treatment There is no specific treatment but
ANALGESICS and plenty of fluid should be avail- Murmur
able. The child may need to be in bed for a few The uneven, rustling sound heard by AUSCUL-
days and should not return to school until the TATION over the HEART and various blood
symptoms have settled. Adults with orchitis vessels in abnormal conditons. For example,
may need strong painkillers, and CORTICO- murmurs heard when the stethoscope is applied
STEROIDS may be required to reduce the painful over the heart are highly characteristic of
swelling. valvular disease of this organ.

Munchausens Syndrome Muscarine

Munchausens syndrome, also known as hos- The poisonous principle found in some toad-
pital addiction syndrome, is a disorder in stools (see FUNGUS POISONING). It is a choliner-
which the patient presents repeatedly to hos- gic substance with pharmacological properties
 Muscle 475

resembling those of ACETYLCHOLINE, a chem- fibres, numerous nuclei, and the endings of
ical neurotransmitter released at the junctions sensory nerves. (See TOUCH.) The heart muscle
(synapses) of parasympathetic nerves and at the comprises short fibres which communicate with
junctions where nerves enter muscles. their neighbours via short branches and have no
sarcolemma.
Muscle Plain or unstriped muscle is found in the
Muscular tissue is divided, according to its following positions: the inner and middle coats
function, into three main groups: voluntary of the STOMACH and INTESTINE; the ureters
muscle, involuntary muscle, and skeletal muscle (see URETER) and URINARY BLADDER; the
of which the first is under control of the will, TRACHEA and bronchial tubes; the ducts of
whilst the latter two discharge their functions glands; the GALL-BLADDER; the UTERUS and
independently. The term striped muscle is FALLOPIAN TUBES; the middle coat of the blood
often given to voluntary muscle, because under and lymph vessels; the iris and ciliary muscle of
the microscope all the voluntary muscles show a the EYE; the dartos muscle of the SCROTUM;
striped appearance, whilst involuntary muscle and in association with the various glands and
is, in the main, unstriped or plain. Heart hairs in the SKIN. The fibres are very much
muscle is partially striped, while certain muscles smaller than those of striped muscle, although
of the throat, and two small muscles inside the they vary greatly in size. Each has one or more
ear, not controllable by willpower, are also oval nuclei and a delicate sheath of sarcolemma
striped. enveloping it. The fibres are grouped in bun-
dles, much as are the striped fibres, but they
Structure of muscle Skeletal or voluntary adhere to one another by cement material, not
muscle forms the bulk of the bodys muscu- by the tendon bundles found in voluntary
lature and contains more than 600 such muscle.
muscles. They are classified according to their
methods of action. A flexor muscle closes a Development of muscle All the muscles
joint, an extensor opens it; an abductor moves a of the developing individual arise from the cen-
body part outwards, an adductor moves it in; a tral layer (mesoderm) of the EMBRYO, each fibre
depressor lowers a body part and an elevator taking origin from a single cell. Later on in life, M
raises it; while a constrictor (sphincter) muscle muscles have the power both of increasing in
surrounds an orifice, closing and opening it. size as the result of use, for example, in ath-
Each muscle is enclosed in a sheath of fibrous letes and also of healing, after parts of them
tissue, known as fascia or epimysium, and, from have been destroyed by injury. An example of
this, partitions of fibrous tissue, known as per- the great extent to which unstriped muscle can
imysium, run into the substance of the muscle, develop to meet the demands made on it is the
dividing it up into small bundles. Each of these uterus, whose muscular wall develops so much
bundles consists in turn of a collection of fibres, during pregnancy that the organ increases from
which form the units of the muscle. Each fibre the weight of 3040 g (11 oz.) to a weight of
is about 50 micrometres in thickness and ranges around 1 kg (2 lb.), decreasing again to its for-
in length from a few millimetres to 300 milli- mer small size in the course of a month after
metres. If the fibre is cut across and examined childbirth.
under a high-powered microscope, it is seen to
be further divided into fibrils. Each fibre is Physiology of contraction A muscle is
enclosed in an elastic sheath of its own, which an elaborate chemico-physical system for pro-
allows it to lengthen and shorten, and is known ducing heat and mechanical work. The total
as the sarcolemma. Within the sarcolemma lie energy liberated by a contracting muscle can
numerous nuclei belonging to the muscle fibre, be exactly measured. From 2530 per cent of
which was originally developed from a simple the total energy expended is used in mechan-
cell. To the sarcolemma, at either end, is ical work. The heat of contracting muscle
attached a minute bundle of connective-tissue makes an important contribution to the main-
fibres which unites the muscle fibre to its tenance of the heat of the body. (See also
neighbours, or to one of the connective-tissue MYOGLOBIN.)
partitions in the muscle, and by means of these The energy of muscular contraction is
connections the fibre affects muscle contrac- derived from a complicated series of chemical
tion. Between the muscle fibres, and enveloped reactions. Complex substances are broken
in a sheath of connective tissue, lie here and down and built up again, supplying each other
there special structures known as muscle- with energy for this purpose. The first reaction
spindles. Each of these contains thin muscle is the breakdown of adenyl-pyrophosphate into
 476 Muscle Relaxants

phosphoric acid and adenylic acid (derived onset of action and lasts approximately three
from nucleic acid); this supplies the immediate minutes. Non-depolarising muscle relaxants
energy for contraction. Next phosphocreatine bind to the acetylcholine receptors, preventing
breaks down into creatine and phosphoric acid, acetylcholine from gaining access to them.
giving energy for the resynthesis of adenyl- They have a slower onset time and longer dur-
pyrophosphate. Creatine is a normal nitrogen- ation than depolarisers, although this varies
ous constituent of muscle. Then glycogen widely between different drugs. They are com-
through the intermediary stage of sugar bound petitive antagonists and they may be reversed by
to phosphate breaks down into lactic acid to increasing the concentration of acetylcholine at
supply energy for the resynthesis of phospho- the motor end-plate using an anticholinesterase
creatine. Finally part of the lactic acid is oxi- agent such as neostigmine. These drugs are
dised to supply energy for building up the rest broken down in the liver and excreted through
of the lactic acid into glycogen again. If there is the kidney, and their action will be prolonged
not enough oxygen, lactic acid accumulates and in liver and renal failure. Other uses include the
fatigue results. relief of skeletal muscle spasms in TETANUS,
All of the chemical changes are mediated by PARKINSONISM and spastic disorders. The drugs
the action of several enzymes (see ENZYME). dantrolene and diazepam are used in these
Involuntary muscle has several peculiarities circumstances.
of contraction. In the heart, rhythmicality is an
important feature one beat appearing to be, in Muscles, Disorders of
a sense, the cause of the next beat. Tonus is a
character of all muscle, but particularly of Compression syndrome The tense, pain-
unstriped muscle in some localities, as in the ful state of muscles induced by excessive
walls of arteries. accumulation of INTERSTITIAL fluid in them,
following unusual exercise. This condition is
Fatigue occurs when a muscle is made to act more liable to occur in the muscles at the front
for some time and is due to the accumulation of of the shin, because they lie within a tight
waste products, especially sarcolactic acid (see fascial membrane: here the syndrome is known
M LACTIC ACID). These substances affect the end- as the anterior tibial syndrome (shin splints).
plates of the nerve controlling the muscle, and Prevention consists of always keeping fit and in
so prevent destructive overaction of the muscle. training for the amount of exercise to be under-
As they are rapidly swept away by the blood, the taken. Equally important is what is known in
muscle, after a rest (and particularly if the rest is sporting circles as warming down: i.e., at the
accompanied by massage or by gentle contrac- end of training or a game, exercise should be
tions to quicken the circulation) recovers rap- gradually tailed off. Treatment consists of eleva-
idly from the fatigue. Muscular activity over the tion of the affected limb, compression of it by
whole body causes prolonged fatigue which is compression bandages, with ample exercise of
remedied by rest to allow for metabolic balance the limb within the bandage, and massage. In
to be re-established. more severe cases DIURETICS may be given.
Occasionally surgical decompression may be
Muscle Relaxants necessary.
These drugs produce partial or complete par-
alysis of skeletal muscle (see under MUSCLE Cramp Painful spasm of a muscle usually
Structure of muscle). Drugs in clinical use are caused by excessive and prolonged contraction
all reversible and are used to help insert a of the muscle fibres. Cramps are common,
breathing tube into the TRACHEA (endotracheal especially among sportsmen and women, nor-
tube) during general ANAESTHESIA and ARTI- mally lasting a short time. The condition usu-
FICIAL VENTILATION OF THE LUNGS. They may ally occurs during or immediately following
be broadly divided into depolarising and non- exercise as a result of a build-up of LACTIC ACID
depolarising muscle relaxants. Depolarising and other chemical by-products in the muscles
muscle relaxants act by binding to acetylcholine caused by the muscular efforts. Cramps may
receptors at the motor end-plate where nerves occur more frequently, especially at night, in
are attached to muscle cells, and producing a people with poor circulation, when the blood is
more prolonged depolarisation than acetyl- unable to remove the lactic acid from the
choline, which results in initial muscle fascicu- muscles quickly enough.
lation (overactivity) and then flaccid paralysis of Repetitive movements such as writing
the muscle. The only commonly used depolar- (writers cramp) or operating a keyboard can
ising drug is succinylcholine which has a rapid cause cramp. Resting muscles may suffer cramp
 Muscles, Disorders of 477

if a person sits or lies in an awkward position linked disorder. It nearly always occurs in
which limits local blood supply to them. Pro- boys.
fuse sweating as a result of fever or hot weather
can also cause cramp in resting muscle, because Symptoms There are three chief types of
the victim has lost sodium salts in the sweat; myopathy. The commonest, known as pseudo-
this disturbs the biochemical balance in muscle hypertrophic muscular dystrophy, affects par-
tissue. ticularly the upper part of the lower limbs of
Treatment is to massage and stretch the children. The muscles of the buttocks, thighs
affected muscle for example, cramp in the and calves seem excessively well developed, but
calf muscle may be relieved by pulling the toes nevertheless the child is clumsy, weak on his
on the affected leg towards the knee. Persist- legs, and has difficulty in picking himself up
ent night cramps sometimes respond to treat- when he falls. In another form of the disease,
ment with a drug containing CALCIUM or which begins a little later, as a rule at about
QUININE. If cramp persists for an hour or the age of 14, the muscles of the upper arm
more, the person should seek medical advice, are first affected, and those of the spine and
as there may be a serious cause such as a lower limbs become weak later on. In a third
blood clot impeding the blood supply to the type, which begins at about this age, the
area affected. muscles of the face, along with certain of
the shoulder and upper arm muscles, show the
Dystrophy See myopathy below. first signs of wasting. All the forms have this in
common: that the affected muscles grow
Inflammation (myositis) of various types weaker until their power to contract is quite
may occur. As the result of injury, an ABSCESS lost. In the first form, the patients seldom
may develop, although wounds affecting reach the age of 20, falling victims to some
muscle generally heal well. A growth due to disease which, to ordinary people, would not
SYPHILIS, known as a gumma, sometimes forms be serious. In the other forms the wasting,
a hard, almost painless swelling in a muscle. after progressing to a certain extent, often
Rheumatism is a vague term traditionally used remains stationary for the rest of life. Myopa-
to define intermittent and often migratory dis- thy may also be acquired when it is the result M
comfort, stiffness or pain in muscles and joints of disease such as thyrotoxicosis (see under THY-
with no obvious cause. The most common ROID GLAND, DISEASES OF), osteomalacia (see
form of myositis is the result of immunological under BONE, DISORDERS OF) and CUSHINGS
damage as a result of autoimmune disease. DISEASE, and the myopathy resolves when the
Because it affects many muscles it is called primary disease is treated.
POLYMYOSITIS.
Treatment Some myopathies may be the
Myasthenia (see MYASTHENIA GRAVIS)
is result of inflammation or arise from an endo-
muscle weakness due to a defect of neuro- crine or metabolic abnormality. Treatment of
muscular conduction. these is the treatment of the cause, with sup-
portive physiotherapy and any necessary phys-
Myopathy is a term applied to an acquired ical aids while the patient is recovering. Treat-
or developmental defect in certain muscles. It is ment for the hereditary myopathies is support-
not a neurological disease, and should be dis- ive since, at present, there is no cure
tinguished from neuropathic conditions (see although developments in gene research raise
NEUROPATHY) such as MOTOR NEURONE DIS- the possibility of future treatment. Physio-
EASE (MND), which tend to affect the distal limb therapy, physical aids, counselling and support
muscles. The main subdivisions are genetically groups may all be helpful in caring for these
determined, congenital, metabolic, drug- patients.
induced, and myopathy (often inflammatory) The education and management of these
secondary to a distant carcinoma. Progressive children raise many difficulties. Much help in
muscular dystrophy is characterised by sym- dealing with these problems can be obtained
metrical wasting and weakness, the muscle from Muscular Dystrophy Campaign.
fibres being largely replaced by fatty and fibrous
tissue, with no sensory loss. Inheritance may Myositis ossificans, or deposition of bone
take several forms, thus affecting the sex and in muscles, may be congenital or acquired. The
age of victims. congenital form, which is rare, first manifests
The commonest type is DUCHENNE MUS- itself as painful swellings in the muscles. These
CULAR DYSTROPHY, which is inherited as a sex- gradually harden and extend until the child is
 478 Muscular Dystrophy

encased in a rigid sheet. There is no effective bones of the skeleton and all the muscles
treatment and the outcome is fatal. attached to them.
The acquired form is a result of a direct blow
on muscle, most commonly on the front of the Mushroom Poisoning
thigh. The condition should be suspected See FUNGUS POISONING.
whenever there is severe pain and swelling fol-
lowing a direct blow over muscle. The diagnosis Mutagen
is confirmed by hardening of the swelling. A chemical or physical agent that has the
Treatment consists of short-wave DIATHERMY property of increasing the rate of MUTATION
with gentle active movements. Recovery is usu- among CELLS. A mutagen does not usually
ally complete. increase the range of mutations. Chemicals,
ionising radiation, and viruses may act as
Pain, quite apart from any inflammation or mutagens.
injury, may be experienced on exertion. This
type of pain, known as MYALGIA, tends to occur Mutation
in unfit individuals and is relieved by rest and A change occurring in the genetic material
physiotherapy. (DNA) in the CHROMOSOMES of a cell. It is
caused by a fault in the replication of a cells
Parasites sometimes lodge in the muscles, genetic material when it divides to form two
the most common being Trichinella spiralis, daughter cells. Mutations may occur in somatic
producing the disease known as TRICHINOSIS cells which may result in a local growth of the
(trichiniasis). new type of cells. These may be destroyed by
the bodys defence mechanism or they may
Rupture of a muscle may occur, without any develop into a tumour. If mutation occurs in a
external wound, as the result of a spasmodic germ cell or gamete the organisms sex cells
effort. It may tear the muscle right across as the outcome may be a changed inherited char-
sometimes happens to the feeble plantaris acteristic in succeeding generations. Mutations
muscle in running and leaping or part of the occur rarely, but a small steady number are
M caused by background radiation in the
muscle may be driven through its fibrous envel-
ope, forming a HERNIA of the muscle. The environment. They are also caused by muta-
severe pain experienced in many cases of LUM- gens (see MUTAGEN). (See also GENETIC
DISORDERS.)
BAGO is due to tearing of one of the muscles in
the back. These conditions are usually relieved
by rest and massage. Partial muscle tears, such Mutism
See under VOICE AND SPEECH.
as occur in sport, require more energetic treat-
ment: in the early stages this consists of the
application of an ice or cold-water pack, firm Myalgia
compression, elevation of the affected limb, rest Pain in a muscle. (See MUSCLES, DISORDERS OF;
BORNHOLM DISEASE; LUMBAGO.)
for a day or so and then gradual mobilisation
(see SPORTS MEDICINE).
Myalgic Encephalomyelitis (ME)
A syndrome in which various combinations of
Tumours occur occasionally, the most com-
extreme fatiguability, muscle pain, lack of con-
mon being fibroid, fatty, and sarcomatous
centration, panic attacks, memory loss and
growths.
depression occur. Its existence and causes have
been the subject of controversy reflected in the
Wasting of muscles sometimes occurs as a variety of names given to the syndrome:
symptom of disease in other organs: for CHRONIC FATIGUE SYNDROME (CFS), post-viral
example, damage to the nervous system, as in fatigue syndrome, Royal Free disease, epidemic
poliomyelitis or in the disease known as neuromyasthenia and Icelandic disease. ME
progressive muscular atrophy. (See PARALYSIS.) often follows virus infections of the upper
respiratory tract or gut, but it is not clear
Muscular Dystrophy whether this is an association or cause-and-
See MUSCLES, DISORDERS OF Myopathy. effect. It may occur in epidemics or as indi-
vidual cases. Physical examination shows no
Musculoskeletal evidence of diagnosable disease and there is no
An adjective that relates to muscle and/or bone. diagnostic test diagnosis usually being made
The musculoskeletal system comprises the by excluding other possible disorders. The suf-
 Mycosis 479

ferer usually recovers in time, although some- sion following thymectomy increases with the
times recovery may take many months or even number of years after the operation. Complete
years. The most severely affected may be bed- remission or substantial improvement can be
ridden and may need tube-feeding. There is no expected in 80 per cent of patients.
specific curative treatment, but symptomatic The other important aspect in the manage-
treatment such as resting in the early stages may ment of patients with myasthenia gravis is
help. Some experts believe that the illness has a IMMUNOSUPPRESSION. Drugs are now available
psychological element, and sufferers have been that suppress antibody production and so
treated with COGNITIVE BEHAVIOUR THERAPY. reduce the concentration of antibodies to the
In 1998 the Chief Medical Officer set up a acetylcholine receptor. The problem is that
multidisciplinary working group, including they not only suppress abnormal antibody pro-
patients, to consider possible cures and treat- duction, but also suppress normal antibody
ments for ME/CFS. The report (2002) con- production. The main groups of immunosup-
cluded that the disorder should be recognised as pressive drugs used in myasthenia gravis are
chronic and treatable, but there was no clear the CORTICOSTEROIDS and AZATHIOPRINE.
agreement on cause(s) and treatment(s). Improvement following steroids may take sev-
Meanwhile research continues, including a pro- eral weeks and an initial deterioration is often
gramme by the Centre of Disease Control in found during the first week or ten days of
Atlanta, USA. Sufferers may find it helpful to treatment. Azathioprine is also effective in pro-
consult the ME Association. ducing clinical improvement and reducing the
antibodies to acetylcholine receptors. These
Myasthenia Gravis effects occur more slowly than with steroids,
A serious disorder in which the chief symptoms and the mean time for an azathioprine remis-
are muscular weakness and a special tendency sion is nine months.
for fatigue to come on rapidly when efforts are The Myasthenia Gravis Association, which
made. The prevalence is around 1 in 30,000. provides advice and help to sufferers, was cre-
Two-thirds of the patients are women, in whom ated and is supported by myasthenics, their
it develops in early adult life. In men it tends to families and friends.
develop later in life. M
It is a classical example of an autoimmune Mycobacterium
disease (see AUTOIMMUNITY). The body A gram-positive (see GRAMS STAIN) rod-like
develops ANTIBODIES which interfere with the genus of aerobic BACTERIA, some species of
working of the nerve endings in muscle that are which are harmful to humans and animals. For
acted on by ACETYLCHOLINE. It is acetylcholine example, M. tuberculosis (Kochs bacillus) and
that transmits the nerve impulses to muscles: if M. leprae cause, respectively, TUBERCULOSIS
this transmission cannot be effected, as in myas- and LEPROSY.
thenia gravis, then the muscles are unable to
contract. Not only the voluntary muscles, but Mycoplasma
those connected with the acts of swallowing, A genus of micro-organisms which differ from
breathing, and the like, become progressively bacteria in that they lack a rigid cell wall. They
weaker. Rest and avoidance of undue exertion are responsible for widespread epidemics in cat-
are necessary, and regular doses of neostigmine tle and poultry. For a long time the only mem-
bromide, or pyridostigmine, at intervals enable ber of the genus known to cause disease in
the muscles to be used and in some cases have a humans was Mycoplasma pneumoniae which is
curative effect. These drugs act by inhibiting responsible for the form of PNEUMONIA known
the action of cholinesterase an ENZYME pro- as primary atypical pneumonia particularly
duced in the body which destroys any excess of common in children, for whom it is the single
acetylcholine. In this way they increase the most common cause of the diseaase when con-
amount of available acetylcholine which com- tracted out of hospital. Another, Mycoplasma
pensates for the deleterious effect of antibodies genitalium, has now been isolated which is
on the nerve endings. responsible for certain cases of non-gonococcal
The THYMUS GLAND plays the major part in urethritis. Mycoplasma infections respond to
the cause of myasthenia gravis, possibly by TETRACYCLINES.
being the source of the original acetylcholine
receptors to which the antibodies are being Mycosis
formed. Thymectomy (removal of the thymus) The general term applied to diseases due to the
is often used in the management of patients growth of fungi in the body. Among some of
with myasthenia gravis. The incidence of remis- the simplest and commonest mycoses are
 480 Mycosis Fungoides

RINGWORM, FAVUS, and thrush (CANDIDA). Myelocyte

The MADURA FOOT of India, ACTINOMYCOSIS, The name given to one of the cells of BONE
and occasional cases of PNEUMONIA and sup- MARROW from which the granular white cells of
purative ear disease are also due to the growth the blood are produced. They are found in the
of moulds in the bodily tissues. Other forms blood in certain forms of LEUKAEMIA.
of mycosis include ASPERGILLOSIS, candidiasis
(see CANDIDA), CRYPTOCOCCOSIS and Myelography
HISTOPLASMOSIS.
The injection of a radio-opaque substance into
the central canal of the SPINAL CORD in order to
Mycosis Fungoides assist in the diagnosis of diseases of the spinal
An old term for a chronic eruption of the skin cord or spine using X-ray examination. Because
characterised by erythematous (see ERYTHEMA) of the high risk of causing damage to the spinal
itching plaques (raised patches on the skin cord (arachnoiditis), it has been largely super-
resulting from the merging or enlargement of ceded by MRI.
papules see PAPULE), which, if left untreated,
eventually form tumours and ulcers. The dis-
ease is now known to be a form of cancer of
Myeloid
lymphocytes (see LYMPHOCYTE) called T-cell An adjective that relates to the granulocyte (see
GRANULOCYTES) precursor cell in the BONE
LYMPHOMA. It may be responsive to PHOTO-
MARROW. For example, myeloid LEUKAEMIA,
CHEMOTHERAPY in its early stages and to
RADIOTHERAPY when more advanced.
which arises from abnormal growth in the
blood-forming tissue of the bone marrow.
Mydriasis
Dilation or widening of the pupil of the EYE. Myeloma
Occurring naturally when it is dark, or when See MYELOMATOSIS.
someone is emotionally aroused, mydriasis can
also result from the administration of ATROPINE Myelomatosis
eye drops. Alcohol consumption also has a A MALIGNANT disorder of PLASMA cells, derived
M mydriatic effect. from B-lymphocytes (see LYMPHOCYTE). In
most patients the BONE MARROW is heavily
Myectomy infiltrated with atypical, monoclonal plasma
Removal of all or part of a muscle by surgery. It cells, which gradually replace the normal cell
may be used to correct a SQUINT (caused by lines, inducing ANAEMIA, LEUCOPENIA, and
unbalanced eye muscles) or to remove a THROMBOCYTOPENIA. Bone absorption occurs,
FIBROID from the muscular wall of the UTERUS. producing diffuse osteoporosis (see under BONE,
DISORDERS OF). In some cases only part of the
Myelin immunoglobulin molecule is produced by the
A substance made up of protein and phospho- tumour cells, appearing in the urine as Bence
lipid that forms the sheath surrounding the Jones PROTEINURIA.
axons of some neurons (see NEURON(E)). These The disease is rare under the age of 30,
are described as myelinated or medullated frequency increasing with age to peak between
nerve fibres, and electric impulses pass along 60 and 70 years. There may be a long pre-
them faster than along non-myelinated nerves. clinical phase, sometimes as long as 25 years.
Myelin is produced by Schwann cells which When symptoms do occur, they tend to reflect
occur at intervals along the nerve fibre. (See bone involvement, reduced immune function,
MULTIPLE SCLEROSIS (MS).) renal failure, anaemia or hyperviscosity of the
blood. Vertebral collapse is common, with
Myelitis nerve root pressure and reduced stature. The
Myelitis is inflammation of the SPINAL CORD. disease is eventually fatal, infection being a
common cause of death. Local skeletal prob-
Myeloblast lems should be treated with RADIOTHERAPY,
Present in the blood-producing tissue in the and the general disease with CHEMOTHERAPY
BONE MARROW, this is a cell with a large chiefly the ALKYLATING AGENTS melphalan
nucleus and scanty cytoplasm. It is the precur- or cyclophosphamide. Red-blood-cell TRANS-
sor cell of a granulocyte (see GRANULOCYTES). FUSION is usually required, together with
Myeloblasts sometimes appear in the blood of plasmapheresis (see PLASMA EXCHANGE), and
patients with various diseases including acute orthopaedic surgery may be necessary follow-
myeloblastic LEUKAEMIA. ing fractures.
 Myrrh 481

Myelosuppression of muscle fibres (see MUSCLE Structure of

A fall in the production of blood cells in the muscle). These muscle tumours often occur in
BONE MARROW. This fall often occurs after the UTERUS.
CHEMOTHERAPY for cancer. ANAEMIA, infection
and abnormal bleeding are symptomatic of Myomectomy
myelosuppression. Removal by surgery of fibroids (see FIBROID)
from the muscular wall of the UTERUS.
Myiasis
Infestation of the SKIN, deeper tissues or Myometrium
the INTESTINE by larvae of the tropical tumbu The muscular coat of the UTERUS.
fly.
Myopathy
Myocardial Infarction See under MUSCLES, DISORDERS OF.
See HEART, DISEASES OF Coronary thrombosis.
Myopia
Myocarditis Sort-sightedness (see under EYE, DISORDERS OF
Inflammation of the muscular wall of the Errors of refraction).
HEART.

Myositis
Myocardium Inflammation of a muscle. (See also MUSCLES,
Myocardium is the muscular substance of the DISORDERS OF Inflammation (myositis)).
HEART. (See also MUSCLE.)

Myoclonus Myositis Ossificans

See under MUSCLES, DISORDERS OF.
A brief, twitching muscular contraction which
may involve only a single muscle or many
muscles (see MUSCLE). It may be too slight to Myotonia
cause movement of the affected limb, or so A condition in which the muscles (see MUSCLE), M
violent as to throw the victim to the floor. though possessed of normal power, contract
The cause is not known, but in some cases only very slowly. The stiffness disappears as the
may be a form of EPILEPSY. A single myo- muscles are used.
clonic jerk in the upper limbs occasionally
occurs in minor motor epilepsy (petit mal). Myringoplasty
The myoclonic jerks which many people The sealing by a surgical tissue-graft of a hole
experience on falling asleep are a perfectly or perforation in the drum (tympanum)
normal phenomenon. which separates the middle and outer sections
of the EAR. It is aimed at improving the sub-
Myoglobin jects hearing (see DEAFNESS); sometimes the
The protein which gives MUSCLE its red colour. operation is done to stop persistent
It has the property of combining loosely and DISCHARGE.
reversibly with OXYGEN; this means that it is the
vehicle whereby muscle extracts oxygen from Myringotomy
the HAEMOGLOBIN in the blood circulating An operation to cut open the drum of the EAR
through it, and then releases the oxygen for use to provide drainage for an infection of the
in muscle METABOLISM. middle ear. It is now done mainly in children
with persistent glue ear (see under EAR, DISEASES
Myoglobinuria OF Diseases of the middle ear).
The occurrence of MYOGLOBIN in the URINE.
This is the oxygen-binding pigment in muscle Myrrh
and mild myoglobinuria may occur during Myrrh is a gum-resin obtained from Com-
exercise. Severe myoglobinuria will result from miphora molmol, an Arabian myrtle tree. It
serious injuries, particularly crushing injuries, stimulates the function of MUCOUS MEMBRANE
to muscles. with which it is brought in contact or by which
it is excreted. Tincture of myrrh is used for a
Myoma gargle in sore throat, as a toothwash when the
The term applied to a TUMOUR, almost invari- gums are inflamed, and as an ingredient of
ably of a simple nature, which consists mainly cough mixtures.
 482 Myxoedema

Myxoedema BONE and, rarely, the HEART. Treatment

See under THYROID GLAND, DISEASES OF involves surgery, which is usually successful.
Hypothyroidism.
Myxoviruses
Myxoma These include the INFLUENZA viruses A, B and
A benign TUMOUR comprising gelatinous CON- C; and the PARAINFLUENZA VIRUSES, types 1 to
NECTIVE TISSUE, most commonly occurring 3. Myxoviruses, which are one of a group of
beneath the SKIN although the condition may RNA-containing viruses, have an affinity for
develop in the ABDOMEN, URINARY BLADDER, protein receptors in red blood cells.

M
 NAI

N See NON-ACCIDENTAL INJURY (NAI).

Nail
See SKIN.

Nail-Biting
Nabilone A common practice in schoolchildren, most of
A CANNABIS-related drug given by mouth and whom gradually give it up as they approach
licensed for use in treating severe nausea and adolescence. Too much significance should
vomiting, particularly when they result from therefore not be attached to it; in itself it does
treatment with anticancer drugs. no harm, and punishment or restraining devices
are not needed. It is a manifestation of tension
Naevus or insecurity, the cause of which should be
A congenitally determined tissue abnormality. removed. In some people the habit is carried
In the SKIN, naevi of blood vessels are best into adulthood.
known, but a MOLE is a MELANOCYTE naevus,
and warty streaked and linear naevi of the epi- Nails, Diseases of
dermis occasionally occur. There are several pat- Disease may affect the nail fold, nail plate or
terns of vascular naevi: nail bed (see SKIN Nail). Inflammation of the
nail fold is called paronychia: acute paronychia
Naevus simplex Also known as salmon is usually caused by a minor injury allowing in
patch. About one-third of white children are bacteria, which set up infection; chronic paro-
born with macular pink areas of ERYTHEMA on nychia is often an occupational hazard, due to
the nape, brow or eyelids which usually disap- constant exposure of the hands to water for
pear after a few months, but patches on the example, in the catering industry, agriculture
nape may persist. and housework but may also be caused by
impaired circulation in the fingers. Often,
ANTIBIOTICS are sufficient for treatment, but
Naevus flammeus Also known as port- sometimes surgical incision is needed.
wine stain and present at birth. It is unilateral, PSORIASIS is a common cause of disease of
usually on the face, and may be extensive. It the nail plate, as are eczema (see DERMATITIS)
tends to darken with age and is permanent. and fungal infection (see FUNGAL AND YEAST
Laser treatment is effective. INFECTIONS). Deformity of the nail may point
to systemic disease, as in CLUBBING, or the
Strawberry naevus (cavernous haeman- spoon-shaped concave nails (koilonychia) of
gioma) is usually not present at birth but severe iron deficiency. Acute toxic illnesses may
appears within a few weeks and grows rapidly, temporarily disturb nail growth causing hori-
reaching a peak in size after 612 months, zontal ridges (Beaus lines) which grow out
when the lobulated red nodule may resemble slowly.
a ripe strawberry. Untreated, the naevus dis- Onycholysis is separation of the nail plate
appears spontaneously over several years. It from its bed. It may be due to psoriasis of the
may occur anywhere and may be very nail bed and trauma, or may occur spon-
troublesome when occurring around an eye or taneously. Gross thickening of nails is common
on the nappy area. If possible it should be in the toes, caused by psoriasis or fungal
left alone, but where it is causing problems infection.
other than simply cosmetic ones it is best
treated by an expert. This may involve med- Nalidixic Acid
ical treatment with steroids or interferon or An antibiotic drug, active against gram-negative
laser therapy. (see GRAMS STAIN) micro-organisms, used to
treat and prevent infections of the URINARY
Spider naevus is due to a dilated ARTERI- TRACT.
OLE causing a minute red papule in the skin,
the small branching vessels resembling spider Nalorphine
legs. A few spider naevi are common in young Nalorphine reduces or abolishes most of the
people, but multiple naevi are common in actions of MORPHINE and similarly acting NAR-
pregnancy and may also be a warning sign of COTICS, such as PETHIDINE HYDROCHLORIDE.
chronic liver disease. It was used as an antidote in the treatment of
 484 Naloxone

overdosage with these drugs but has now been Narcissism

superseded by NALOXONE. An abnormal mental state characterised by
excessive admiration of ones self. In Greek
Naloxone mythology, Narcissus so loved staring at his
An effective drug in the treatment of opioid own reflection in water that he eventually fell in
poisoning. It blocks the effects of most opiates; and drowned.
given intravenously, it acts within 23 minutes.
The drug is also given to newborn babies whose Narcolepsy
breathing has been depressed by narcotic drugs A condition in which uncontrollable episodes
given to their mothers to relieve pain during of sleep occur two or three times a day. It starts
childbirth. at any age and persists for life. The attacks,
which usually last for 1015 minutes, come on
Naltrexone suddenly at times normally conducive to sleep,
A drug that is an ANTAGONIST to narcotic sub- such as after a meal, or sitting in a bus, but they
stances (see NARCOTICS). Given orally, it is used may occur when walking in the street. In due
in the maintenance treatment of HEROIN and course, usually after some years, they are associ-
other opiate-dependent people. ated with cataplectic attacks (see CATAPLEXY),
when for a few seconds there is sudden muscu-
Nandrolone lar weakness affecting the whole body. The
One of the ANABOLIC STEROIDS, with the prop- cataplectic attacks can be controlled by the TRI-
erty of building PROTEIN. It is of little value in CYCLIC ANTIDEPRESSANT DRUGS, imipramine
medical care, although is licensed for use in or clomipramine.
aplastic ANAEMIA; it has also been used in the Familial narcolepsy is well recognised, and
past to treat osteoporosis in women (see under recently a near-100-per-cent association
BONE, DISORDERS OF), but is no longer recom- between narcolepsy and the histocompatability
mended for this purpose. Its use as a body- antigen HLA-DR2 (see HLA SYSTEM) has been
builder by some athletes and others has caused discovered, which suggests that narcolepsy is an
controversy: those found using it are barred from immunorelated disease. The Narcolepsy
most recognised athletic events. Nandrolone Association (UK) has been founded to help
should never be taken by pregnant women or by patients with this strange disorder.
N people with liver disease or prostate cancer. Side-
effects include ACNE; VIRILISATION with high Narcosis
doses including voice changes, cessation of A condition of stupor (see under UNCONSCIOUS-
periods, and inhibition of sperm production; NESS), resembling sleep, that is usually caused
and liver tumours after prolonged use. by a drug. It may also occur as a result of liver or
kidney failure which causes URAEMIA. The
Nanometre affected person has significantly reduced aware-
A nanometre is a millionth of a millimetre. The ness and is hard to arouse. Treatment is of the
approved abbreviation is nm. (See APPENDIX 6: underlying cause and the normal precautions
MEASUREMENTS IN MEDICINE.) for caring for an unconscious or semiconscious
subject should be taken. (See APPENDIX 1: BASIC
Nappy Rash FIRST AID.).
A common form of irritant contact DERMATITIS
in the nappy area in babies under one year old. Narcotics
Wetting of the skin by urine, abrasion, and Substances that induce stupor and eventually
chemical changes due to faecal contamination UNCONSCIOUSNESS. Used in the relief of severe
all play a part. Good hygiene and use of dispos- pain, people can become first tolerant of them
able absorbent nappies have much reduced its so requiring larger doses and then dependent
incidence. An ointment containing a barrier, (see also ANALGESICS; HYPNOTICS; TOLERANCE;
such as titanium dioxide, may help; other DEPENDENCE).
medications such as mild CORTICOSTEROIDS or
antibiotics should be used very cautiously and Nasal Congestion
only under the guidance of a doctor, as harmful The nose and nasal sinuses (see SINUS) produce
effects may result especially from overuse. up to a litre of MUCUS in 24 hours, most of
which enters the stomach via the NASOPHAR-
Naproxen YNX. Changes in the nasal lining mucosa occur
See under NON-STEROIDAL ANTI-INFLAMMATORY in response to changes in humidity and atmos-
DRUGS (NSAIDS). pheric temperature; these may cause severe
 National Institute for Clinical Excellence (NICE) 485

congestion, as might an allergic reaction or National Electronic Library for

nasal polyp. Health
This National Health Service initiative went
Treatment Topical nasal decongestants online in November 2000. It aims to provide
include sodium chloride drops and cortico- health professionals with easy and fast access to
steroid nasal drops (for polyps). For common- best current knowledge from medical journals,
cold-induced congestion, vapour inhalants, professional group guidelines, etc. Unbiased
decongestant sprays and nasal drops, including data can be accessed by both clinicians and the
EPHEDRINE drops, are helpful. Overuse of public.
decongestants, however, can produce a rebound
congestion, requiring more treatment and National Health Service (NHS)
further congestion, a tiresome vicious circle. The United Kingdoms National Health Ser-
Allergic RHINITIS (inflammation of the nasal vice was created by Act of Parliament and
mucosa) usually responds to ipratropium brom- inaugurated on 5 July 1948. Its original aim
ide spray. was to provide a comprehensive system of
Systemic nasal decongestants given by health care to everyone, free at the point of
mouth are not always as effective as topical delivery. Scotland had its own, similar legisla-
administrations but they do not cause rebound tion, as did Northern Ireland. The service is
congestion. Pseudoephedrine hydrochoride is funded by National Insurance contributions
available over the counter, and most common- and from general taxation, with a small
cold medicines contain anticongestant amount from patient charges. The structure,
substances. functioning and financing of the NHS have
been and still are undergoing substantial
Nasogastric Tube changes.
A small-bore plastic or rubber tube passed into
the stomach through the nose, pharynx and National Infection Control and
then the oesophagus. It is used either to aspirate Health Protection Agency
gas and liquid from the stomach or to pass food A National Health Service body intended to
or drugs into it. combat the increasing threat from infectious
diseases and biological, chemical and radio-
logical hazards. Covering England, the agency N
Nasolacrimal Duct
A duct that goes through the nasolacrimal canal includes the Public Health Laboratory Service,
in the palatine bone of the SKULL. The duct the National Radiological Protection Board, the
drains the tears from the lacrimal (tear) glands Centre for Applied Microbiology and Research,
into the NOSE. and the National Focus Group for Chemical
Incidents.
Nasopharynx National Institute for Clinical
Nasopharynx is the upper part of the throat, Excellence (NICE)
lying behind the nasal cavity. (See NOSE.) This special health authority in the National
Health Service, launched in 1999, prepares
National Blood Authority formal advice for all managers and health pro-
This body manages regional TRANSFUSION fessionals working in the service in England and
centres. Among its aims are the maintenance Wales on the clinical- and cost-effectiveness of
and promotion of blood and blood products new and existing technologies. This includes
based on a system of voluntary donors; imple- diagnostic tests, medicines and surgical pro-
menting a cost-effective national strategy for cedures. The institute also gives advice on best
ensuring adequate supplies of blood and its practice in the use of existing treatments.
products to meet national needs; and ensuring NICE its Scottish equivalent is the Scottish
high standards of safety and quality. Health Technology Assessment Centre has
three main functions:
National Care Standards appraisal of new and existing technologies.
Commission development of clinical guidelines.
This was set up under the CARE STANDARDS
2000 as an independent regulator in
promotion of clinical audit and confidential
inquiries. Central to its task is public concern
ACT
respect of homes for the elderly, the disabled about postcode prescribing that is, differ-
and children in the state and private sectors in ent availability of health care according to
the UK. geography.
 486 National Listening Library

In 2003 the World Health Organisation can be given in this way. It has the advantage
appraised NICE. Amongst its recomendations over a metered dose inhaler (MDI) that no spe-
were that there should be greater consistency in cial effort is required to coordinate breathing,
the methods used for appraisal and the way in and a nebuliser allows a much greater volume of
which results and decisions were reported. the drug to be delivered to where it is needed
WHO was concerned about the need for trans- (the airways) compared with that of MDIs. The
parency about the conflict between NICEs use use of higher doses of bronchodilator drugs
of manufacturers commercial evidence in con- made possible by the nebuliser means that the
fidence, and believed there should be greater risk of unwanted side-effects is also increased.
definition of justification for threshold levels Fortunately the safety profile of anti-asthmatic
for cost-effectiveness in the Centres judgement drugs such as salbutamol is extremely high and
of what represents value for money. overdose is generally well-tolerated.
In all, WHO was congratulatory but ques-
tions remain about the practical value and Necator Americanus
imlementation of NICE guidelines. A hookworm, closely resembling but smaller
than the Ancylostoma duodenale. (See
National Listening Library ANCYLOSTOMIASIS.)
National Listening Library is a charity which
produces recorded books for handicapped Necropsy
people who cannot read, with the exception of A traditional term for an autopsy or POST-
the blind who have their own separate organisa- MORTEM EXAMINATION.
tion, the Royal National Institute for the Blind.
(See also CALIBRE.) Necrosis
Death of a limited portion of tissue, the term
Natriuresis being most commonly applied to bones when,
The excretion of SODIUM in the URINE, particu- as the result of disease or injury, a fragment dies
larly if the amount excreted is more than nor- and separates. (See BONE, DISEASES OF.)
mal. An agent that causes this sodium excretion
usually a diuretic (see DIURETICS) is termed a Necrotising Fasciitis
natriuretic. Also known as CELLULITIS. A potentially lethal
N infection caused by the gram-positive (see
Nausea GRAMS STAIN) bacterium Streptococcus pyogenes
The sensation that VOMITING is about to occur; which has the property of producing dangerous
however, nausea does not always lead to exotoxins. The infection, which starts in the
vomiting. layer of FASCIA under the SKIN, may spread very
rapidly, destroying tissue as it spreads. Urgent
Navel antibiotic treatment may check the infection,
Navel, or UMBILICUS, is the scar on the abdo- and surgery is sometimes required, but even
men marking the point where the umbilical with treatment patients may die (see
cord joined the body in embryonic life. (See STREPTOCOCCUS).
PLACENTA.)
Needle-Stick Injury
Near Sight Accidental perforation of the skin by an injec-
Myopia. See under EYE, DISORDERS OF Errors of tion needle, commonly of the hand or finger
refraction. and usually by a nurse or doctor administering
a therapeutic injection. The term also refers to
Nebula accidental injuries from injection needles dis-
The term applied to a slight opacity on the cor- carded by drug abusers. Dangerous infections
nea (see EYE) producing a haze in the field of such as viral HEPATITIS or HIV may be acquired
vision, and also to any oily preparation to be from needle-stick injuries, and there are strict
sprayed from a nebuliser an apparatus for procedures about the disposal of used syringes
splitting up a fluid into fine droplets. and needles in medical settings.

Nebulisers Needling
A nebuliser makes an aerosol (see under INHAL- An operation performed in the treatment of
ANTS) by blowing air or oxygen through a cataracts (see under EYE, DISORDERS OF), in
solution of a drug. Many inhaled drugs such as which the anterior lens capsule of the EYE is
SALBUTAMOL, ipratropium and beclomethasone torn open with a needle, allowing the aqueous
 Neonatology 487

fluid to dissolve the opaque soft lens matter, for the treatment of certain forms of ENTERITIS
which is gradually washed away into the blood- due to E. coli.
stream. This extra-capsular extraction may
need to be repeated several times before all the Neonatal
opaque lens matter disperses. Although a rela- Pertaining to the first month of life.
tively simple procedure, it is unsuitable for
patients over the age of 35 (when the nucleus of Neonatal Intensive Care
the lens becomes increasingly hard), and CRYO- The provision of a dedicated unit with special
SURGERY and LASER therapy have become the facilities, including one-to-one nursing and
preferred methods of treatment. appropriate technology, for caring for pre-
Needling is also used for certain minor der- mature and seriously ill newborn babies. Paedi-
matological procedures, such as removal of atricians and neonatologists are involved in the
small facial cysts and scabies mites. running of such units. Not every maternity unit
can provide intensive care: for example, the
Nefopam Hydrochloride provision of artificial ventilation, other than as a
A non-opioid analgesic drug (see ANALGESICS) holding procedure until a baby can be trans-
of use in the relief of pain that fails to respond ferred to a better-equipped and better-serviced
to other non-opioid analgesics. It causes little unit. Such hospitals tend to have special-care
depression of respiration but side-effects may be baby units, which are capable of looking after
a problem. the needs of most, but not all, premature or ill
babies.
Negativism
Negativism means a morbid tendency in a per- Neonatal Mortality
son to do the opposite of what he or she is Neonatal mortality is the mortality of infants
desired or directed to do. It is especially charac- under one month of age. In England and Wales
teristic of those suffering from SCHIZOPHRENIA, this has fallen markedly in recent decades: from
but is not uncommon in non-psychotic persons. more than 28 per 1,000 live births in
1939 to 3.6 in 2002. This improvement can be
Negligence attributed to various factors: better antenatal
See MEDICAL NEGLIGENCE. supervision of expectant mothers; care to ensure
that expectant mothers receive adequate nour- N
Neisseriaceae ishing food; improvements in the management
A family of bacteria of which three varieties of the complications of pregnancy and of
cause disease. Neisseria meningitidis causes labour; and more skilled resuscitation at birth
meningococcal MENINGITIS and SEPTICAEMIA. for those who need it.
It is divided into three groups: A, B and C; Nearly three-quarters of neonatal deaths
group B accounts for most meningitis cases in occur during the first week of life. For this rea-
the UK, mostly affecting children. Neisseria son, increasing emphasis is being laid on this
gonorrhoeae causes GONORRHOEA. The bacteria initial period of life. In Britain, in the last four
are gram-negative (see GRAMS STAIN) cocci usu- decades of the 20th century, the number of
ally occurring in pairs. A third variety is Morax- deaths in the first week of life fell dramatically
ella catarrhalis: this occurs in the nose and from 13.2 to just over 2.7 per 1,000 live births.
throat and sometimes causes ear infection and The chief causes of deaths in this period are
low-grade infection of the respiratory tract. extreme prematurity (less than 28 weeks gesta-
tion), birth asphyxia with oxygen lack to the
Nematode brain, and congenital abnormalities. After the
A roundworm. (See ASCARIASIS.) first week the commonest cause is infection.

Neomycin Neonatology
Neomycin is one of the AMINOGLYCOSIDES, The branch of PAEDIATRICS responsible for the
derived from Streptomyces fradiae. It has a wide medical care of newborn babies. Problems may
antibacterial spectrum, being effective against be short term for example, those linked to
the majority of gram-negative (see GRAMS prematurity or life-long such as CEREBRAL
STAIN) bacilli. Its use is limited by the fact that PALSY. After the first few weeks of life, paedi-
it is liable to cause deafness and kidney damage. atricians take over the responsibility for any
Its main use is for application to the skin specialist medical care required, with general
either in solution or as an ointment for the practitioners looking after the infants primary-
treatment of infection; it is also given by mouth care needs.
 488 Neoplasm

Neoplasm (e.g. urea, drugs, etc.). The tubules eventually

This means literally a new formation and is empty the filtrate, which by now is urine, into
another word for a benign or non-malignant the renal pelvis from where it flows down the
TUMOUR. ureters into the bladder. (See KIDNEYS.)

Neostigmine Nephropathy
An ANTICHOLINESTERASE drug which enhances A description of any damage or disease to the
neuromuscular transmission the passage of kidneys (see KIDNEYS, DISEASES OF).
chemical messages between nerve and muscle
cells in voluntary and involuntary muscles in Nephropexy
patients with the disorder MYASTHENIA GRAVIS. Surgical fixation (to the 12th rib and posterior
Its effect lasts for about four hours. A disadvan- abdominal wall) of a mobile kidney; this
tage is that it has a marked cholinergic action prevents the kidney from descending in the
affecting heart rhythm, causing excessive abdomen when the affected person stands up.
salivation and tear secretion, constricting the
BRONCHIOLES and stimulating the gastrointest- Nephroptosis
inal tract. The condition in which a kidney (see KIDNEYS)
is mobile or floating instead of being fixed to
Nephrectomy the back of the abdominal cavity.
The operation for removal of the kidney. (See
KIDNEYS, DISEASES OF.) Nephroscope
An endoscopic instrument for examining the
Nephritis inside of the kidney (see KIDNEYS). It is normally
Inflammation of the kidneys. (See KIDNEYS, DIS- passed into the renal pelvis of the organ via a
EASES OF Glomerulonephritis.) route from the surface of the skin. Instruments
can be passed through the nephroscope under
Nephroblastoma direct vision to remove CALCULI (stones) or
Nephroblastoma, or Wilms tumour, is the break them up using ULTRASOUND.
commonest kidney tumour in infancy (see also
KIDNEYS, DISEASES OF Tumours of the kid- Nephrostomy
N ney). It is a malignant tumour, which occurs in Nephrostomy is the operation of making an
around 1 per 10,000 live births. The survival opening into the kidney (see KIDNEYS) to drain
rate with modern treatment (removal of the it.
kidney followed by radiotherapy and chemo-
therapy) is now around 80 per cent. Nephrotic Syndrome
Nephrotic syndrome is one of PROTEINURIA,
Nephrolithiasis hypo-albuminaemia and gross OEDEMA. The
A condition in which CALCULI are present in primary cause is the leak of albumin (see ALBU-
the kidney. MINS) through the GLOMERULUS. When this
exceeds the livers ability to synthesise albumin,
Nephrology the plasma level falls and oedema results. The
The branch of medicine concerned with the nephrotic syndrome is commonly the result of
study and management of kidney disease. A primary renal glomerular disease (see KIDNEYS,
specialist in these diseases is called a DISEASES OF Glomerulonephritis). It may also
nephrologist. be a result of metabolic diseases such as diabetic
glomerular sclerosis and AMYLOIDOSIS. It may
Nephron be the result of systemic autoimmune diseases
Each kidney comprises over a million of these such as SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
microscopic units which regulate and control and POLYARTERITIS NODOSA. It may complicate
the formation of URINE. A tuft of capillaries malignant diseases such as MYELOMATOSIS and
invaginates the Bowmans capsule, which is the Hodgkins disease (see LYMPHOMA). It is some-
blind-ending tube (GLOMERULUS) of each times caused by nephrotoxins such as gold or
nephron. Plasma is filtered out of blood and mercury and certain drugs, and it may be the
through the Bowmans capsule into the renal result of certain infections such as MALARIA and
tubule. As the filtrate passes along the tubule, CROHNS DISEASE.
most of the water and electrolytes are
reabsorbed. The composition is regulated with Nephrotomy
the retention or addition of certain molecules Nephrotomy means the operation of cutting
 Nervous System 489

into the kidney (see KIDNEYS), in search of defective nerve may occur. When the nerve in
CALCULI or for other reasons. question is a motor one, the muscles governed
through it are instantly paralysed. In the latter
Nerve case, the portion of nerve beyond the injury
A nerve is a bundle of conductory fibres called degenerates and the muscles gradually waste,
axons (see AXON) that emanate from neurones losing their power of contraction in response to
(see NEURON(E)) the basic anatomical and electrical applications. Finally, deformities
functional units of the NERVOUS SYSTEM. result and the joints become fixed. This is par-
Nerves make up the central nervous system ticularly noticeable when the ulnar nerve is
(BRAIN and SPINAL CORD) and connect that sys- injured, the hand and fingers taking up a claw-
tem to all parts of the body, transmitting like position. The skin may also be affected.
information from sensory organs via the per-
ipheral nerves to the centre and returning Treatment Damaged or severed (peripheral)
instructions for action to the relevant muscles nerve fibres should be sewn together, using
and glands. microsurgery. Careful realignment of the nerve
Nerves vary in size from the large pencil- endings gives the fibres an excellent chance of
sized sciatic nerve in the back of the thigh regenerating along the right channels. Full
muscles to the single, hair-sized fibres distrib- recovery is rare but, with regular physiotherapy
uted to the skin. A nerve, such as the sciatic, to keep paralysed muscles in good shape and to
possesses a strong, outer fibrous sheath, called prevent their shortening, the patient can expect
the epineurium, within which lie bundles of to obtain a reasonable return of function after a
nerve-fibres, divided from one another by few weeks, with improvement continuing over
partitions of fibrous tissue, in which run blood several months.
vessels that nourish the nerve. Each of these
bundles is surrounded by its own sheath, Nervous Breakdown
known as the perineurium, and within the A non-medical description of a variety of emo-
bundle fine partitions of fibrous tissue, known as tional crises ranging from an outburst of hyster-
endoneurium, divide up the bundle into groups ical behaviour to a major neurotic illness that
of fibres. The finest subdivisions of the nerves are may have a lasting effect on an individuals life.
the fibres, and these are of two kinds: medul- Sometimes the term is used to describe an overt
lated and non-medullated fibres. (See NEUR- psychotic illness for example, SCHIZOPHRENIA N
ON(E) and NERVOUS SYSTEM for more details on (see also MENTAL ILLNESS; NEUROSIS).
structure and functions of neurons and nerves.)
Nervous Impulse
Nerve Block This is transmitted chemically, by the forma-
See ANAESTHESIA Local anaesthetics. tion at nerve-endings of chemical substances.
When, for example, a NERVE to a muscle is
Nerve Cell stimulated, there appears at the NEURO-
See NEURON(E). MUSCULAR JUNCTION the chemical substance,
ACETYLCHOLINE. Acetylcholine also appears at
Nerves, Injuries to endings of the parasympathetic nerves (see NER-
These have several causes. Continued or VOUS SYSTEM) and transmits the effect of the
repeated severe pressure may damage a nerve parasympathetic impulse. When an impulse
seriously, as in the case of a crutch pressing into passes down a sympathetic nerve, the effect of it
the armpit and causing drop-wrist. Bruising is transmitted at the nerve-ending by the chem-
due to a blow which drives a superficially placed ical liberated there: ADRENALINE or an
nerve against a bone may damage, say, the radial adrenaline-like substance.
nerve behind the upper arm. A wound may
sever nerves, along with other structures; this Nervous System
accident is specially liable to occur to the ulnar This extensive, complex and finely tuned net-
nerve in front of the wrist when a person acci- work of billions of specialised cells called
dentally puts a hand and arm through a pane of neurones (see NEURON(E)) is responsible for
glass. maintaining the bodys contacts with and
responses to the outside world. The network
Symptoms When a sensory nerve is injured also provides internal communication links in
or diseased, sensation is immediately more or concert with HORMONES, the bodys chemical
less impaired in the part supplied by the nerve. messengers between the bodys diverse organs
Ulceration or death of the tissue supplied by the and tissues, and, importantly, the BRAIN stores
 490 Nervous System, Disorders of

relevant information as memory. Each neurone tem include the ability to experience emotions,
has a filamentous process of varying length such as excitement and pleasure, anxiety and
called an AXON along which passes messages in frustration, and to undertake intellectual activ-
the form of electrochemically generated ities. For these experiences an individual can
impulses. Axons are bundled together to form utilise many built-in neurological programmes
nerves (see NERVE). and he or she can enhance performance
The nervous system can be likened to a com- through learning a vital human function that
puter. The central processing unit which depends on MEMORY, a three stage-process in
receives, processes and stores information and the brain of registration, storage and recall. The
initiates instructions for bodily activities is various anatomical and functional divisions of
called the central nervous system: this is made the nervous system that have been unravelled as
up of the brain and SPINAL CORD. The per- science has strived to explain how it works may
ipheral nervous system synonymous with the seem confusing. In practical terms, the nervous
cables that transmit information to and from a system works mainly by using automatic or
computers processing unit has two parts: relex reactions (see REFLEX ACTION) to various
sensory and motor. The former collects infor- stimuli (described above), supplemented by
mation from the bodys many sense organs. voluntary actions triggered by the activity of the
These respond to touch, temperature, pain, conscious (higher) areas of the brain. Some
position, smells, sounds and visual images and higher functions crucial to human activity for
the information is signalled to the brain via the example, visual perception, thought, memory
sensory nerves. When information has been and speech are complex and subtle, and the
processed centrally, the brain and spinal cord mechanisms are not yet fully understood. But
send instructions for action via motor nerves to all these complex activities rest on the founda-
the voluntary muscles controlling movements tion of relatively simple electrochemical
and speech, to the involuntary muscles that transmissions of impulses through the massive
operate the internal organs such as the heart network of billions of specialised cells, the
and intestines, and to the various glands, neurones.
including the sweat glands in the skin. (Details
of the 12 pairs of cranial nerves and the 31 pairs Nervous System, Disorders of
of nerves emanating from the spinal cord are The following conditions are discussed under
N given in respective texts on brain and spinal their individual headings: APHASIA; BRAIN,
cord.) DISEASES OF; CATALEPSY; CHOREA; CRAMP;
EPILEPSY; HYSTERIA; LEARNING DISABILITY;
Functional divisions of nervous sys- MEMORY; MENTAL ILLNESS; MULTIPLE SCLER-
tem As well as the nervous systems anatom- OSIS (MS); NERVES, INJURIES TO; NEURALGIA;
ical divisions, the system is divided functionally, NEURITIS; PARALYSIS; PSYCHOSOMATIC DIS-
into autonomic and somatic parts. The auto- EASES; SPINE AND SPINAL CORD, DISEASES AND
nomic nervous system, which is split into sym- INJURIES OF; STROKE; TABES.
pathetic and parasympathetic divisions, deals
with the automatic or unconscious control of Nettle-Rash
internal bodily activities such as heartbeat, See URTICARIA.
muscular status of blood vessels, digestion and
glandular functions. The somatic system is Neuralgia
responsible for the skeletal (voluntary) muscles Pain which is the result of damage to or irrita-
(see MUSCLE) which carry out intended move- tion of a NERVE. The pain tends to be intermit-
ments initiated by the brain for example, the tent, occurring in short bursts. It may be very
activation of limbs, tongue, vocal cords severe and be located along an identifiable
(speech), anal muscles (defaecation), urethral nerve. A particular disorder may give rise to
sphincters (urination) or vaginal muscles neuralgia, MIGRAINE being an example, and
(childbirth). In addition, many survival HERPES ZOSTER (shingles) another. Neuralgia
responses the most powerfully instinctive may also be caused by disturbance to a particu-
animal drives, which range from avoiding dan- lar nerve for instance, trigeminal neuralgia
ger and pain to shivering when cold or sweating which affects the sensory nerve supplying most
when hot are initiated unconsciously and of the face.
automatically by the nervous system using the
appropriate neural pathways to achieve the par- Treatment Any obvious underlying cause
ticular survival reaction required. should be dealt with. Neuralgia may be symp-
The complex functions of the nervous sys- tomatically relieved with ANALGESICS. Severe
 Neuroleptics 491

pain may be helped by the analgesic car- In polyneuritis, usually due to some general
bamazepine or by destroying (freezing, local or constitutional cause, the nerve-fibres them-
alcohol injection or surgery) the affected nerve. selves in the small nerves degenerate and break
down. The condition is protracted because, for
Neural Tube recovery to occur, the growth of new nerve-
The structure in the EMBRYO from which the fibres from the healthy part of the nerve has to
BRAIN and SPINAL CORD develop. take place. The cause of polyneuritis may be
infection by a virus for example, HERPES
Neural Tube Defects ZOSTER or a bacterium, as in LEPROSY. Neur-
Congenital abnormalities resulting from the itis may also be the result of agents such as
failure of the NEURAL TUBE to form normally. alcohol, lead or products from industrial or
The resulting conditions include SPINA BIFIDA, agricultural activities. ORGANOPHOSPHORUS
MENINGOCELE and defects in the bones of the insecticides are believed by some to be a factor
SKULL. in neuritis and other neurological conditions.

Neurasthenia Neuroblastoma
An out-of-date term that was used to describe A malignant growth comprising embryonic
an ill-defined state of nervous exhaustion in nerve cells. It may start in any part of the
which, although the patient suffers from no AUTONOMIC NERVOUS SYSTEM. The medulla of
definite disease, he or she becomes incapable of the adrenal gland (see under ENDOCRINE
sustained exertion. The condition which it rep- GLANDS) is a common site; secondary growths
resented is now believed to be a form of NEUR- develop in other tissues. Neuroblastomas are
OSIS or psychosomatic disease. It was also used the most common extracranial solid tumour of
in the past to describe what is now called childhood. The incidence is around eight cases
CHRONIC FATIGUE SYNDROME (CFS). per one million children. Treatment is by sur-
gery followed by radiotherapy and CYTOTOXIC
Neurectomy drugs. About 30 per cent of sufferers survive for
An operation in which part of a NERVE is at least five years after treatment.
excised: for example, for the relief of
NEURALGIA. Neurodermatoses
See under SKIN, DISEASES OF. N
Neurilemma
The thin membranous covering which sur- Neurofibrils
rounds every nerve-fibre. (See NERVE.) A microscopic strand of CYTOPLASM that occurs
in the cell body of a NEURON(E) as well as in the
Neuritis semifluid content of the AXON of a nerve cell.
Inflammation affecting a nerve or nerves which
may be localised to one part of the body as, Neurofibromatosis
for instance, in SCIATICA or which may be See VON RECKLINGHAUSENS DISEASE.
general, being then known as multiple neuritis,
or POLYNEURITIS. Owing to the fact that the Neuroglia
most peripheral parts of the nerves are usually The fine web of tissue and branching cells
affected in the latter condition (i.e. the fine which supports the nerve-fibres and cells of the
subdivisions in the substance of the muscles), it nervous system. (See NERVE.)
is also known as peripheral neuritis.
Neuroleptics
Causes In cases of localised neuritis, the Drugs used to quieten disturbed patients,
fibrous sheath of the nerve is usually at fault, whether this is the result of brain damage,
the actual nerve-fibres being only secondarily MANIA, DELIRIUM, agitated DEPRESSION or an
affected. This condition may be due to inflam- acute behavioural disturbance. They relieve the
mation spreading into the nerve from surround- florid PSYCHOTIC symptoms such as hallucin-
ing tissues; to cold; or to long-continued ations and thought-disorder in SCHIZOPHRENIA
irritation by pressure on the nerve. The symp- and prevent relapse of this disorder when it is in
toms produced vary according to the function remission.
of the nerve, in the case of sensory nerves being Most of these drugs act by blocking DOPA-
usually neuralgic pain (see NEURALGIA), and in MINE receptors. As a result they can give rise to
the case of motor nerves some degree of par- the extrapyramidal effects of PARKINSONISM
alysis in the muscles to which the nerves pass. and may also cause HYPERPROLACTINAEMIA.
 492 Neurology

Troublesome side-effects may require control tions, acetylcholine will compete with the drug
by ANTICHOLINERGIC drugs. The main anti- and dislodge it from the receptor; the effect of
psychotic drugs are: (i) chlorpromazine, metho- these drugs is reversed by giving an anti-
trimeprazine and promazine, characterised by cholinesterase, which allows the amount of
pronounced sedative effects and a moderate acetylcholine at the neuromuscular junction to
anticholinergic and extrapyramidal effect; (ii) build up. These drugs have varying durations of
pericyazine, pipothiazine and thioridazine, action, but all are slower in onset and of longer
which have moderate sedative effects and duration than the depolarisers.
marked anticholinergic effects, but less extrapy-
ramidal effects than the other groups; (iii) flu- Neuromuscular Junction
phenazine, perphenazine, prochlorperazine, The area where a motor NERVE ends close to the
sulpiride and trifluoperazine, which have fewer MUSCLE membrane so can initiate muscle con-
sedative effects and fewer anticholinergic traction. The motor-nerve ending is separated
effects, but more pronounced extrapyramidal from the motor end plate by the synaptic cleft
effects. which is only 5070 nm wide. When a nerve
impulse arrives at the motor-nerve ending,
Neurology molecules of ACETYLCHOLINE are released
The branch of medical practice and science which cross the synaptic cleft and attach to
which is concerned with the study of the NER- receptors on the motor end plate. This initiates
VOUS SYSTEM and its disorders. Specialists in depolarisation of the muscle which in turn ini-
neurology neurologists examine a patients tiates the process of contraction. Acetylcho-
nerves, sensory and motor functions and linesterase (an ENZYME) rapidly breaks down
reflexes. They use modern imaging techniques the molecules of acetylcholine, thus ending
for example, CT scanning (see COMPUTED their action and freeing the receptor in prepar-
TOMOGRAPHY) and MRI to aid diagnosis. ation for the next impulse.
Until relatively recently, many neurological
conditions could be treated only with palliative Neuron(e)
methods. Now there is much improved under- Also known as a nerve cell, this is the basic
standing of the nervous system and its dis- cellular building-block of the NERVOUS SYSTEM,
orders, with closer liaison between psychiatrists which contains billions of neurones linked in a
N (see PSYCHIATRY) and neurologists. complex network and acting in different com-
binations to keep the body informed about the
Neuroma outside world, and then to organise and activate
Neuroma means a TUMOUR connected with a appropriate responses. There are three main
NERVE such tumours being generally com- types of neurone:
posed of fibrous tissue, and of a painful nature.
Sensory These carry signals to the central
Neuromuscular Blockade nervous system (CNS) the BRAIN and SPINAL
In clinical practice, the transmission of CORD from sensory receptors. These receptors
impulses at the NEUROMUSCULAR JUNCTION respond to different stimuli such as touch, pain,
may be blocked to paralyse temporarily a temperature, smells, sounds and light.
patient for a surgical procedure, or to assist
treatment on the intensive care unit. There are Motor These carry signals from the CNS to
two main types of drug, both of which com- activate muscles or glands.
petitively block the ACETYLCHOLINE receptors
on the motor end plates. (1) Depolarising Interneurons These provide the intercon-
neuromuscular blocking agents: these act by necting electrical network within the CNS.
first producing stimulation at the receptor, and
then by blocking it. There are characteristic Structure Each neurone comprises a cell
muscle fasciculations before the rapid onset of body, several branches called dendrites, and a
paralysis which is of short duration (less than single filamentous fibre called an AXON. Axons
five minutes with the commonly used drug, may be anything from a few millimetres to a
suxamethonium). The drug is removed from metre long; at their end are several branches
the receptor by the enzyme, CHOLINESTERASE. acting as terminals through which electro-
(2) Non-depolarising neuromuscular blocking chemical signals are sent to target cells, such as
agents: these drugs occupy the receptor and those of muscles, glands or the dendrites of
prevent acetylcholine from becoming attached another axon.
to it. However, in sufficiently high concentra- Axons of several neurones are grouped
 Neuron(e) 493

together to form nerve tracts within the brain

or spinal cord or nerve-fibres outside the CNS.
Each nerve is surrounded by a sheath and con-
tains bundles of fibres. Some fibres are medul-
lated, having a sheath of MYELIN which acts as
insulation, preventing nerve impulses from
spreading beyond the fibre conveying them.
The cellular part of the neurones makes up
the grey matter of the brain and spinal cord
the former containing 600 million neurones.
The dendrites meet with similar outgrowths
from other neurones to form synapses. White
matter is the term used for that part of the sys-
tem composed of nerve fibres.

Functions of nerves The greater part of

the bodily activity originates in the nerve cells
(see NERVE). Impulses are sent down the nerves
which act simply as transmitters. The impulse
causes sudden chemical changes in the muscles
as the latter contract (see MUSCLE). The
impulses from a sensory ending in the skin pass
along a nerve-fibre to affect nerve cells in the
spinal cord and brain, where they are perceived
as a sensation. An impulse travels at a rate of
about 30 metres (100 feet) per second. (See
NERVOUS IMPULSE.)
The anterior roots of spinal nerves consist of
motor fibres leading to muscles, the posterior
roots of sensory fibres coming from the skin.
The terms, EFFERENT and AFFERENT, are N
applied to these roots, because, in addition to
Diagram of neurone. motor fibres, fibres controlling blood vessels
and secretory glands leave the cord in the
anterior roots. The posterior roots contain, in
addition to sensory fibres, the nerve-fibres that
transmit impulses from muscles, joints and
other organs, which among other neurological
functions provide the individual with his or her

Diagram showing nervous connections between the central nervous system and muscle and skin.
 494 Neuropathic Bladder

Diagram of a reflex arc.

proprioceptive faculties the ability to know imaging (MRI) techniques have provided very
how various parts of the body are positioned. clear images of nerve tracts in the brain which
The connection between the sensory and should lead to greater understanding of how
motor systems of nerves is important. The sim- the brain functions.) (See BRAIN; NERVOUS SYS-
plest form of nerve action is that known as TEM; SPINAL CORD.)
automatic action. In this, a part of the nervous
system, controlling, for example, the lungs, Neuropathic Bladder
N makes rhythmic discharges to maintain the A URINARY BLADDER with complete or partial
regular action of the respiratory muscles. This loss of sensation. As there is no sensation of
controlling mechanism may be modified by fullness, the individual either develops com-
occasional sensory impressions and chemical plete retention of URINE, or the bladder empties
changes from various sources. automatically usually every few hours. The
condition predisposes affected individuals to
Reflex action This is an automatic or urinary-tract infections and back pressure on
involuntary activity, prompted by fairly simple the KIDNEYS, leading to renal failure. It may be
neurological circuits, without the subjects con- caused by spinal injury, SPINA BIFIDA or any
sciousness necessarily being involved. Thus a disorder which produces NEUROPATHY.
painful pinprick will result in a reflex with-
drawal of the affected finger before the brain Neuropathology
has time to send a voluntary instruction to the The branch of PATHOLOGY that covers the
muscles involved. reasons for and consequences of disorders of the
NERVOUS SYSTEM (see also NEUROLOGY).
Voluntary Actions are more complicated
than reflex ones. The same mechanism is Neuropathy
involved, but the brain initially exerts an A disease affecting nerves (see NERVE). It may
inhibitory or blocking effect which prevents affect a single nerve (mononeuropathy) or be a
immediate reflex action. Then the impulse, generalised disorder (polyneuropathy). Symp-
passing up to the cerebral hemispheres, stimu- toms will depend on whether motor, sensory, or
lates cellular activity, the complexity of these autonomic nerves are affected. Trauma or
processes depending upon the intellectual pro- entrapment of a nerve is a common cause of
cesses involved. Finally, the inhibition is mononeuropathy, pressure or stretching of a
removed and an impulse passes down to motor nerve occurring in various situations. Complete
cells in the spinal cord, and a muscle or set of recovery in 46 weeks is usual. Common causes
muscles is activated by the motor nerves. of polyneuropathy include DIABETES MELLITUS,
(Recent advances in magnetic resonance vitamin B deficiency (often alcohol-associated)
 NHS Direct 495

and some viral infections. Genetic and toxic Neurotransmitter

neuropathies are also seen. A chemical substance which transmits the
action of a NERVE to a cell (see CELLS). It is
Neurosis released from nerve-endings and transmits the
A general term applied to mental or emotional impulse across synapses (see SYNAPSE) to other
disturbance in which, as opposed to PSYCHOSIS, nerves. In the central nervous system the sub-
there is no serious disturbance in the perception stances acting as neurotransmitters include
or understanding of external reality. However, ACETYLCHOLINE, NORADRENALINE, DOPAMINE
the boundaries between neurosis and psychosis and SEROTONIN. The main transmitter in the
are not always clearly defined. Neuroses are peripheral system is acetylcholine, while for the
usually classified into anxiety neuroses, depres- sympathetic system it is noradrenaline. In
sive neuroses, phobias (see PHOBIA), HYPOCHON- recent years a new group of neurotransmitters
DRIASIS, HYSTERIA and obsessional neuroses. called neuropeptides has been identified, com-
prising large protein molecules. One of the
Anxiety neurosis, or anxiety state, consti- best-known is that of endorphins, which the
tutes the most common form of neurosis; for- brain uses to control pain. (See also NEURON(E);
tunately it is also among the most responsive to NERVOUS SYSTEM; PAIN.)
treatment. Once the neurosis develops, sufferers
are in a state of persistent anxiety and worry, Neutron
tensed up, always fatigued and unable to sleep A neutron is one of the particles that enter into
at night. In addition, there are often physical the structure of the atomic nucleus. (See
complaints for example, palpitations, sweat- ISOTOPE.)
ing, apparent discomfort on swallowing (glo-
bus), and headache.
Neutropenia
Obsessional neuroses are much less A reduction in the number of neutrophil
LEUCOCYTES per cubic millimetre of circulating
common and constitute only about 5 per cent
of all neuroses. Like other neuroses, they usually blood to a figure below that found in health.
develop in early adult life. (See MENTAL There is still some disagreement over the precise
ILLNESS.)
limits of normality, but a count of fewer than
1,500 per mm3 would be generally accepted as N
constituting neutropenia. Several infective dis-
Neurosurgery eases are characterised by neutropenia,
Surgery performed on some part of the NER-
including typhoid fever (see ENTERIC FEVER),
VOUS SYSTEM, whether brain, spinal cord or
INFLUENZA and MEASLES. It may also be
nerves. Disorders treated by neurosurgeons
induced by certain drugs, including chlor-
include damage to the brain, spinal cord and
amphenicol, the sulphonamides and
nerves as a result of injury; tumours in the CEN-
chlorpromazine.
TRAL NERVOUS SYSTEM; abnormalities of blood
vessels in or supplying blood to the brain for
example, ANEURYSM; brain abscess; bleeding Neutrophil
inside the skull; and certain birth defects such A type of leucocyte or white blood cell (see
LEUCOCYTES; BLOOD).
as HYDROCEPHALUS and SPINA BIFIDA.

Neurotic NHS
A vague term applied to a person of nervous See NATIONAL HEALTH SERVICE (NHS).
temperament, whose actions are largely deter-
mined by emotions or instincts rather than by NHS Direct
reason. A government-initiated, countrywide,
telephone-based helpline which enables mem-
Neurotoxin bers of the public with a potential emergency or
A chemical substance that harms nervous tissue, inquiry about health to receive counselling over
causing symptoms of numbness or weakness of the telephone. They can then be advised on the
the body part supplied by the damaged NERVE. most appropriate course of action: perhaps an
The venom of some snakes contains neurotoxic urgent visit to the nearest Accident & Emer-
substances, and bacteria may produce neuro- gency department, a non-urgent visit to the
toxins: examples are those that cause DIPH- general practitioner, or even self-medication.
THERIA and TETANUS. Arsenic and lead are The intention is to reduce the high workloads
examples of inorganic neurotoxins. of GPs and A&E departments without
 496 NHS Executive

endangering patients. NHS Direct is expected Nicotinic Acid

to be enhanced to provide: Nicotinic acid is a member of the vitamin B
links to community pharmacies and social
services.
complex. It is essential for human nutrition, the
normal daily requirement for an adult being
access to NHS Direct information via the about 1520 mg. A deficiency of nicotinic acid
Internet and information points in public is one of the factors in the etiology of PEL-
sites. LAGRA, and either nicotine acid or NICOTINA-
publication of a guide on health care for dis- MIDE is used in the treatment of this condition.
patch to callers. Nicotinic acid also reduces the concentration of
blood lipids (see HYPERLIPIDAEMIA).
NHS Executive
The top management body in the health ser- Nidus
vice. It is part of the Department of Health. A site of infection within the body from which
it can spread to other tissues.
NHS Litigation Authority
See MEDICAL LITIGATION. Nifedipine
A member of the CALCIUM-CHANNEL
NHS Modernisation Board BLOCKERS group of cardiovascular drugs. It
A group of senior health- and social-care profes- relaxes vascular smooth muscle and dilates cor-
sionals, frontline staff, managers and patients onary and peripheral arteries. Nifedipine has
representatives set up in 2000 to advise the Sec- been used to prevent and treat ANGINA PEC-
TORIS and certain types of HYPERTENSION.
retary of State for Health on the implementa-
tion of the NHS plan a ten-year programme
for improving the service. Night Blindness
See under BLINDNESS.

Niclosamide Night Sweats

A widely used anthelmintic drug (see ANTHEL- Copious PERSPIRATION occurring in bed at
MINTICS) for treating TAENIASIS or tapeworm
night and found in conditions such as TUBER-
infection. CULOSIS, BRUCELLOSIS and lymphomas (see
N LYMPHOMA), as well as thyrotoxicosis (see under
Nicotinamide THYROID GLAND, DISEASES OF), anxiety states
Nicotinamide, the amide of NICOTINIC ACID, is and menopausal flushes (see MENOPAUSE).
usually used instead of the latter in the treat-
ment of vitamin B deficiency. Nipple
The small, sensitive prominence at the tip of
Nicotine each breast (see BREASTS) containing (in
An alkaloid which is the principal addictive women) the small openings through which
agent in TOBACCO. The small amount of nico- milk can pass from the milk glands in the breast
tine in a single cigarette is sufficient to stimulate tissue. The nipple and its surrounding area (the
mental and bodily activities. In larger quantities areola) are darker than the adjacent skin. The
it acts as a depressant or narcotic habitual area becomes darker during pregnancy.
smokers may find its effect sedating. Nicotine
works by stimulating the production of a chem- Nipples, Diseases of
ical called DOPAMINE, a neurotransmitter or See BREASTS, DISEASES OF.
chemical messenger between nerve cells. Nico-
tine mimics the action of a neurotransmitter Nitrates
called ACETYLCHOLINE. Nerve cells that pro- Chemical compounds that have a valuable role
duce dopamine have acetylcholine-receptor in the treatment of ANGINA PECTORIS. They are
molecules on their surfaces; when these very effective in dilating the ARTERIES supplying
nicotine-like receptors are occupied by acetyl- the HEART; their prime benefit, however, is to
choline molecules, a cell is prompted to reduce the return of venous blood to the heart
produce dopamine. So nicotine itself can (via the superior and inferior venae cavae), thus
artificially stimulate dopamine production. reducing the demands on the left ventricle,
Dopamine is part of the neuronal circuitry that which pumps deoxygenated blood to the lungs.
plays a part in the bodys perception of pleas- Undesirable side-effects such as flushing, head-
ure, which is why smoking is enjoyed by many ache and postural HYPOTENSION may restrict
people. the use of nitrates. Among the nitrate drugs
 Nocturnal Enuresis 497

used is GLYCERYL TRINITRATE which, taken ANALGESICS; PAIN) and mild ANAESTHESIA dur-
under the tongue (sublingually), provides ing childbirth, during painful dental pro-
quick, symptomatic relief of angina, lasting for cedures, and at the site of major accidents. It
up to half an hour. Alternative administration has a rapid action and the effects do not last for
can be via a spray product. Isorbide dinitrate long.
taken sublingually is a more stable preparation,
suitable for patients who need nitrates Nociceptors
infrequently. The drugs effect may last for 12 NERVE endings which detect and respond to
hours in modified-release form. Patients taking painful or unpleasant stimuli.
long-acting nitrates or preparations absorbed
through the skin (transdermal) may develop Nocturia
TOLERANCE. Excess passing of URINE during the night.
Among its many causes are glomerulonephritis
Nitrazepam (see under KIDNEY, DISEASES OF) and enlargement
A tranquilliser introduced as a hypnotic. It is of the PROSTATE GLAND.
long-acting and may produce drowsiness next
day. Addiction can occur. (See TRANQUILLISERS; Nocturnal Enuresis
HYPNOTICS; BENZODIAZEPINES.) The involuntary passing of URINE during sleep.
It is a condition predominantly of childhood,
Nitric Oxide (NO) and usually genetically determined. Sometimes,
A naturally occurring chemical that performs a however, it is a symptom of anxiety in a child,
wide range of biological roles. It is involved in especially if there has been over-rigorous
the laying down of memories in the BRAIN; in attempts at toilet-training or hostile or unlov-
killing viruses, bacteria and cancer cells; and in ing behaviour by a parent. It can also be pro-
helping to control blood pressure. NO, com- voked by apparently unimportant changes in a
prising a nitrogen atom attached to an oxygen childs life for example, moving house. In a
one, is one of the smallest of biologically active small minority of cases it is due to some
compounds as well as having such diverse func- organic cause such as infection of the genito-
tions. The chemical is a muscle relaxant and is urinary tract.
important in maintaining the heart and circula- The age at which a child achieves full con-
tion in good condition. NO is also the toxic trol of bladder function varies considerably. N
agent released by macrophages (see MACRO- Such control is sometimes achieved in the sec-
PHAGE) to kill invading germs and spreading ond year, but much more commonly not until
cancer cells. It acts as an essential NEURO- 23 years old. Some children do not normally
TRANSMITTER and protects nerve cells against achieve such control until the fourth, or even
stress. Researchers are studying how it might be fifth, year, so that paediatricians are reluctant
used to treat diseases, for example by using it as to make this diagnosis before a child is aged
an inhaled gas in certain respiratory conditions. six.
The approach consists essentially of reassur-
Nitrofurantoin ance and firm but kindly and understanding
A synthetic nitrofuran derivative which has a training. In most cases the use of a star chart
wide range of antibacterial activity and is effect- and a buzzer alarm which wakens the child
ive against many gram-positive and gram- should he or she start passing urine is helpful.
negative (see GRAMS STAIN) micro-organisms. It Where there are relationship or social problems,
is used mainly in the treatment of infections of these need to be considered in treating the
the lower URINARY TRACT. child. The few who have urinary infection or
irritable bladders may respond to drug
Nitrogen Mustards tretament.
The nitrogen analogues of mustard gas are Those who do not respond may be helped by
among the most important ALKYLATING DDAVP, an analogue of a pituitary hormone,
AGENTS used in the treatment of various forms which reduces the amount of urine produced
of malignant disease. They include chlorme- overnight. It is licensed for use for three months
thine, busulphan, chlorambucil and melphalan. at a time. Some children prefer to reserve it for
occasions such as sleeping away from home.
Nitrous Oxide Gas The antidepressant imipramine can help some
Also known as laughing gas, this is (at ordinary children but has to be used cautiously because
pressures) a colourless, sweetish-smelling gas. It of side-effects.
is used with oxygen to provide relief of pain (see For help, contact www.eric.org.uk
 498 Node

Node five years to around 70,000 a year. It produces

The term node is widely used in medicine. For pelvic inflammatory disease in women, which
instance, the smaller lymphatic glands are often often results in sterility, the risk of ECTOPIC
termed LYMPH NODES. It is also applied to a PREGNANCY, and recurrent pelvic pain. Most
collection of nerve cells forming a subsidiary cases respond well to TETRACYCLINES. Abstin-
nerve centre found in various places in the ence from sexual intercourse should be
sympathetic nervous system (see NERVOUS SYS- observed during treatment and until cure is
TEM), such as the sinuatrial node and the atrio- complete. Children born to infected mothers
ventricular node which control the beating of may have their eyes infected during birth, pro-
the HEART. ducing the condition known as ophthalmia
neonatorum. This is treated by the application
Noise to the eye of chlortetracycline eye ointment.
See DEAFNESS; OCCUPATIONAL DISEASES. The lungs of such a child may also be infected,
resulting in pneumonia.
Noma
Another name for CANCRUM ORIS. Non-Steroidal Anti-
Inflammatory Drugs (NSAIDs)
Nomifensine These act by inhibiting the formation of PROS-
See ANTIDEPRESSANT DRUGS. TAGLANDINS which are mediators of INFLAM-
MATION. They act both as ANALGESICS to
Non-Accidental Injury (NAI) relieve pain, and as inhibitors of inflammation.
(See also CHILD ABUSE). Though NAI has trad- Aspirin is a classic example of such a com-
itionally been seen as abuse against children pound. Newer compounds have been syn-
and they are still the main victims such injur- thesised with the aim of producing fewer and
ies can also be inflicted on vulnerable adults. less severe side-effects. They are sometimes pre-
Adults with learning difficulties, dementias or ferred to aspirin for the treatment of conditions
physical disabilities sufficiently serious as to such as RHEUMATOID ARTHRITIS, OSTEO-
require institutional care (or who make heavy ARTHRITIS, sprains, strains and sports injuries.
demands on relatives) are sometimes the vic- Their main side-effects are gastrointestinal: gas-
tims of NAI. Health professionals, social work- tric ulcers and gastric haemorrhage may result
N ers and relatives should bear this possibility in (see STOMACH, DISEASES OF). This is because
mind when discovering unusual, severe or prostaglandins are necessary for the production
repeated bruising or fractures in vulnerable of the mucous protective coat in the stomach
adults, even in circumstances where NAI may and, when the production of prostaglandin is
seem unlikely. (See also MUNCHAUSENS SYN- inhibited, the protection of the stomach is
DROME; PAEDOPHILIA.) compromised. NSAIDs should therefore be
used with caution in patients with DYSPEPSIA
Non-Conventional Medicine and gastric ulceration. The various non-
An umbrella term to describe alternative, com- steroidal anti-inflammatory drugs differ little
plementary, folk and other types of healing from each other in efficacy, although there is
practices that are outside the definition of con- considerable variation in patient response. Ibu-
ventional western-type medical practice. (See profen is one of the first choices in this group of
COMPLEMENTARY AND ALTERNATIVE MEDICINE drugs as it combines good efficacy with a low
(CAM).) incidence of side-effects and administration is
only required twice daily. Other drugs in this
Non-Hodgkins Lymphoma series include diclofenac, fenbufen, fenclofenac,
See LYMPHOMA. fenoprofen, feprazone, flurbiprofen, indometh-
acin, indoprofen, ketoprofen, ketorolac,
Non-Proprietary Name naproxen, piroxicam, sulindac, tiaprofenic acid
See GENERIC DRUG; APPROVED NAMES FOR and tolmetin.
MEDICINES.
Noradrenaline
Non-Specific Urethritis (NSU) A precursor of ADRENALINE in the medulla of
An inflammatory condition of the URETHRA the suprarenal glands (see ADRENAL GLANDS). It
due to a cause or causes other than GONOR- is also present in the BRAIN. Its main function is
RHOEA. The most common is CHLAMYDIA tra- to mediate the transmission of impulses in the
chomatis there has been a rise of over 75 per SYMPATHETIC NERVOUS SYSTEM; it also has a
cent in the incidence in the UK over the past transmitter function in the brain.
 Nose, Disorders of 499

Norepinephrine bone (sphenoidal sinus); and in the lateral part

See NORADRENALINE. of the ethmoid bone (ethmoidal sinus). The
sinuses drain into the interior of the nose, as
Norethisterone does the Eustachian or auditory tube from the
A synthetic preparation that has the action of middle ear (see EAR).
PROGESTERONE, but is active when given by
mouth. Nose, Disorders of
Certain skin diseases particularly CHILBLAIN,
Norm ACNE, LUPUS and ERYSIPELAS tend to affect
The expected value for something measurable. the NOSE, and may be very annoying. Redness
Most people have measurements lying to either of the skin may be caused by poor circulation in
side of the norm. Traditionally in medicine, cold weather.
only those lying beyond two standard devi-
ations from the norm are considered likely to be Acute inflammation is generally the result
abnormal (approximately 3 per cent of those of a viral infection (see COLD, COMMON) affect-
measured). (See STANDARD DEVIATION.) ing the mucous membrane and paranasal
sinuses (see SINUSITIS); less commonly it results
Normal from the inhalation of irritant gases. Boils may
A term used in several different senses. Gener- develop just inside the entrance to the nose,
ally speaking, it is applied to anything which causing pain; these are potentially troublesome
agrees with the regular and established type. In as infection can spread to the sinuses. HAY
chemistry, the term is applied to solutions of FEVER is one distressing form of acute rhinitis.
acids or bases of such strength that each litre
contains the number of grams corresponding to Malformations are of various kinds. Racial
the molecular weight of the substance in ques- and familial variations in the external nose
tion. In physiology the term normal is applied occur and may be a reason for RHINOPLASTY.
to solutions of such strength that, when mixed Differences in the size and shape of the nose
with a body fluid, they are ISOTONIC and cause occur, often forming the starting point for
no disturbance: for example, normal saline chronic inflammation of the nose, perennial
solution. rhinitis (all the year round), hay fever, or
ASTHMA. More commonly, obstruction results N
Normoblast from nasal polyps or adenoids, leading to inhal-
The precursor of an erythrocyte (see ERYTHRO- ation through the mouth. Adenoids are an
CYTES; BLOOD) which still contains the rem- overgrowth of glandular tissue at the back of the
nant of a NUCLEUS. throat, into which the nose opens. Polyps are
growths of soft jelly-like character: they arise
Normotensive from chronic inflammation associated with
Having a BLOOD PRESSURE within the NORMAL allergic rhinitis, chronic sinusitis, asthma, and
range for an individuals age and sex. aspirin abuse. Large polyps can cause erosion of
the nasal bones and should be surgically
Nortriptyline removed.
One of the ANTIDEPRESSANT DRUGS; also a
sedative. Bleeding (see HAEMORRHAGE).

Nose Foreign bodies At first these may not cause

In the course of RESPIRATION, incoming air any symptoms, but in time they can cause
enters via the nose and is here warmed, mois- obstruction of the affected nostril with a foul-
tened, and filtered before entering the lungs. smelling bloody discharge. The problem is
The nose has a protective function, irritant air common with small children who tend to push
being expelled by SNEEZING. It is also the organ small objects into their noses. Foreign bodies
of SMELL. require removal, sometimes in hospital. Anyone
Several sinuses (see SINUS) lie concealed in the attempting to remove a foreign body should
bones of the SKULL, into which air enters freely take care not to push it further into the nose.
by apertures connecting them with the nose.
These cavities occupy spaces in the frontal bone Loss of sense of smell, or anosmia, may
over the eyebrow (frontal sinus); in the upper be temporary or permanent. Temporary
jaw-bone, filling in the angle between the EYE anosmia is caused by conditions of the nose
and the nose (maxillary sinus); in the sphenoid which are reversible, whereas permanent
 500 Nose, Disorders of

The lateral wall of the right half of the nasal cavity.

anosmia is caused by conditions which destroy are usually good, ensuring a clear airway as well
the OLFACTORY NERVES. Temporary conditions as a restored profile. It is not unusual for the
are those such as the common cold, or other cheek-bone to sustain a depressed fracture at
inflammatory conditions of the nasal mucosa or the same time as the nose is broken. Careful
the presence of nasal polyps (see above). Per- assessment and prompt surgery are called for.
manent anosmia may follow influenzal NEUR- (For more information on fractures, see under
ITIS or it may also follow injuries to the brain BONE, DISORDERS OF).
and fractures of the skull involving the olfactory
nerves. Rhinitis Inflammation of the MUCOUS MEM-
BRANE lining the nose. Symptoms include nasal
Injury to nose The commonest injury is a discharge and obstruction, sneezing and some-
fracture of the nasal bones or displacement of times pain in the sinuses. There are several types
the cartilage that forms the bridge of the nose. of rhinitis:
The nasal SEPTUM may also be displaced side- Allergic due to allergy to dust, pollen or
ways by a lateral blow. Sporting activities, espe- other airborne particles. Also called hay fever,
cially boxing and rugby football, are commonly allergic rhinitis causes a runny nose, sneezing
a cause of nasal injury. If a fracture is suspected, and local congestion. It affects up to 10 per
or if there is substantial tissue swelling, an X-ray cent of the population and is more common
examination is necessary. Resetting a damaged in people suffering from other allergic dis-
bone should be done either immediately, before orders such as asthma or eczema (see
swelling makes surgery difficult, or ten days or DERMATITIS). Skin tests help to identify the
so later when the swelling has subsided. Results causative ALLERGEN which the sufferer can
 Nucleic Acid 501

then try to avoid, although in the case of Leptospirosis

pollen this is difficult. Decongestant drugs, Malaria
ANTIHISTAMINE DRUGS, and CORTICO- Marburg disease
STEROIDS may help, as can SODIUM CROMO- Measles
GLYCATE inhaled regularly during the pollen Meningitis
season. A desensitisation course to a particu- Meningococcal septicaemia (without menin-
lar allergen sometimes provides long-term gitis)
relief. Mumps
Atrophic rhinitis is caused by a deterioration Ophthalmia neonatorum
in the nasal mucous membrane as a result of Paratyphoid fever
chronic bacterial infection, nasal surgery or Plague
AGEING. Symptoms include persistent nasal Rabies
infection and discharge and loss of sense of Relapsing fever
smell. ANTIBIOTICS and, in some cases, OES- Rubella
TROGENS alleviate the symptoms. Scarlet fever
Hypertrophic rhinitis results from repeated
nasal infection, and is characterised by thick-
Smallpox
Tetanus
ened nasal membranes and congestion of the Tuberculosis
nasal veins. Removal of thickened mucosa Typhoid fever
may help severe cases. Typhus
Vasomotor rhinitis occurs when the mucosa Viral haemorrhagic fever (including Lassa fever)
becomes oversensitive to stimuli such as pol- Viral hepatitis
lutants, temperature changes or certain foods Whooping cough
or medicines. It may occur as a result of emo- Yellow fever
tional disturbances and is common in Reporting AIDS is voluntary (and in
pregnancy. confidence) to the Director, Communicable
Viral rhinitis occurs as a result of infection by
the common cold virus; treatment is symp-
Diseases Surveillance Centre (PHLS).

tomatic. Sinusitis is sometimes a NSAIDs

complication. See NON-STEROIDAL ANTI-INFLAMMATORY
DRUGS (NSAIDS).
N
Nosology
The term applied to scientific classification of
diseases.
NSU
See NON-SPECIFIC URETHRITIS (NSU).
Nostrils
See NOSE. Nucha
The Latin name for the back of the neck.
Notifiable Diseases (Adjective nuchal.)
Diseases, usually of an infectious nature, which
are required by law to be made known to a Nuclear Magnetic Resonance
health officer or local authority. (See INFEC-
TION.) Certain occupational diseases are also
(NMR)
notifiable.
See MAGNETIC RESONANCE IMAGING (MRI).
Notifiable diseases in the UK (For more
information on a specific disease, refer to the Nuclear Medicine
separate dictionary entry.) The branch of medicine concerned with the use
Acute encephalitis of radioactive material in the diagnosis, investi-
Acute poliomyelitis gation and treatment of disease.
Anthrax
Cholera Nucleic Acid
Diphtheria A substance constructed out of units known as
Dysentery (amoebic or bacillary) nucleotides which consist of a purine or pyr-
Ebola virus disease imidine base linked to a pentose sugar, which in
Food poisoning turn is esterified with phosphoric acid. Two
Lassa fever types of nucleic acid occur in nature: deoxy-
Leprosy (reported to Chief Medical Officer at ribonucleic acid (DNA) and ribonucleic acid
the Department of Health) (RNA).
 502 Nucleoside Reverse Transcriptase Inhibitor

Nucleoside Reverse eer opportunities for nurses and other health

Transcriptase Inhibitor professionals. The new model emphasises the
See REVERSE TRANSCRIPTASE INHIBITOR. practical aspects of the education programme
with a better response to the needs of patients
Nucleus and the NHS. It also offers nurses a more flex-
The central body in a cell, which controls the ible career path and education linked more
activities of the latter. (See CELLS.) closely with practice development and research,
so as to provide greater scope for continuing
Nucleus Pulposus professional education and development.
The inner core of an intervertebral disc. (See About 60 per cent of RNs work in NHS
SPINAL COLUMN.) hospitals and community trusts. But an increas-
ing number are choosing to work elsewhere,
Nullipara either in the private sector or in jobs such as
The term applied to a woman who has never school nursing, occupational health or for NHS
borne a child. Direct, the nurse-led telephone helpline.
Others have dropped out of nursing altogether.
Numbness The health service is facing a shortage of quali-
See TOUCH. fied nurses and many trust employers have
resorted to overseas recruitment drives. The
Nursing government has launched a major nurse
Nurses are the largest single group of staff work- recruitment and retention campaign and is
ing in the health service. There are more than promoting family-friendly employment prac-
330,000 qualified nursing posts in NHS trusts tices to lure those with a nursing qualification
and primary care across the UK. Would-be currently working outside the NHS back
registered nurses (RNs) do either a three-year into the workforce. Nursing is a mainly female
diploma programme or a four-year degree. An profession and a third of nurses work
increasing number of nurses are now acquiring part-time.
degrees, either as their initial qualification or by Nurses pay has for long compared unfavour-
studying part-time later in their career. This has ably with other professional employment
led to an often heated debate over the nature of opportunities, despite being determined by an
N nursing and whether there is now too much independent Pay Review Body. With the
emphasis on academic theory at the expense of recruitment of nurses a perennial problem, the
hands-on care. governments strategy, Making a Difference, is
Nursing is changing rapidly, and todays to set up a new pay system offering greater
nurses are expected to take on an extended role flexibility and opportunities for nurses and
often performing tasks which were once the other health-service staff. In 2005, a newly
sole preserve of doctors, such as diagnosing, qualified staff nurse earned around 16,000 a
prescribing drugs and admitting and dis- year, while one of the new grade of consultant
charging patients. nurses could command an annual salary of
There are four main branches of nursing: between 27,000 and 42,000. Nurse consult-
adult, child, mental health and learning dis- ants were introduced in spring 2000 as a means
ability. Student nurses qualify in one of these of allowing nurses to progress up the career
areas and then apply to go on the nursing regis- ladder while maintaining a clinical role.
ter. This is held by nursings regulatory body, The nurse of today is increasingly likely to be
the Council for Nursing and Midwifery. Nurses part of a multidisciplinary team, working
are expected to abide by the Councils Code of alongside a range of other professionals from
Professional Conduct. The organisations main doctors and physiotherapists to social workers
role is protecting the public and it is responsible and teachers. A further sign of the times is that
for monitoring standards and dealing with alle- many registered nurses are being asked to act in
gations of misconduct. There are more than a supervisory role, delegating tasks to non-
637,000 qualified nurses on the Councils regis- registered nurses working as health-care
ter, and this is the main pool from which the assistants and auxiliaries. In recognition of the
NHS and other employers recruit. latters increasing role, the Royal College of
The criticisms about nurses education being Nursing, the main professional association and
too academic, and persisting problems of trade union for nurses, has now agreed to
recruitment of nurses into the NHS, were extend membership to health-care assistants
among factors prompting a strategic govern- with a Scottish/National Vocational Qualifica-
ment review of the status, training, pay and car- tion at level three.
 Nystatin 503

Midwifery Midwives (see MIDWIFE) are prac- from diet to child behavioural problems. They
titioners who offer advice and support to are employed by health trusts, primary-care
women before, during and after pregnancy. groups and primary-care trusts.
They are regulated by the Council for Nursing
and Midwifery (formerly the UK Central Nutrition
Council for Nursing, Midwifery and Health The process by which the living organism
Visiting). Registered nurses can take an 18- physiologically absorbs and uses food to ensure
month course to become a midwife, and there is growth, energy production and repair of tissues.
also a three-year programme for those who wish The science of nutrition includes the study of
to enter the profession directly. Midwifery diets and deficiency diseases (see DIET).
courses lead to a diploma or degree-level quali-
fication. Most midwives work for the NHS Nystagmus
and, as with nursing, there are problems recruit- See under EYE, DISORDERS OF.
ing and retaining staff.
Nystatin
Health visiting Health visitors are regis- An antibiotic, isolated from Streptomyces
tered nurses who work in the community with a noursei, active against Candida albicans (see
range of groups including families, the home- CANDIDA). It is not absorbed from the gut but
less and older people. They focus on preventing is useful in gastrointestinal and skin candidosis.
ill-health and offer advice on a range of topics

N
 output, per person and also when expressed

O against fat-free mass than do their lean coun-

terparts. Most obese people do not appear to
have a reduced capacity for thermogenesis.
Although a genetic component to obesity
remains a possibility, it is unlikely to be great or
to prevent weight loss from being possible in
Oat Cell most patients by reducing energy intake.
A type of cell found in one highly malignant Environmental influences are believed to be
form of lung cancer. The cell is small and either more important in explaining the familial
oval or round. The nucleus stains darkly and association in obesity.
the cytoplasm is sparse and difficult to identify. An inactive lifestyle plays a minor role in the
Oat-cell, or small-cell, carcinoma of the bron- development of obesity, but it is unclear
chus is usually caused by smoking, and com- whether people are obese because they are
prises around 30 per cent of all bronchial can- inactive or are inactive because they are obese.
cers. It responds to radiotherapy and chemo- For the majority of obese people, the explan-
therapy but, because the growth has usually ation must lie in an excessive energy intake.
spread widely by the time it is diagnosed, the Unfortunately, it is difficult to demonstrate this
prognosis is poor. Results of surgery are directly since the methods used to assess how
unsatisfactory. much people eat are unreliable. For most obese
people it seems likely that the defect lies in their
Obesity failure to regulate energy intake in response to a
A condition in which the energy stores of the variety of cognitive factors (e.g. ease of fitting of
body (mainly fat) are too large. It is a prevalent clothes) in the long term.
nutritional disorder in prosperous countries Unfortunately, it can be possible to identify
increasingly so among children and young by the time of their first birthday, many of the
people. The Quetelet Index or BODY MASS children destined to be obese.
INDEX, which relates weight in kilograms (W) Rarely, obesity has an endocrine basis and is
to height2 in metres (H2), is a widely accepted caused by hypothyroidism (see under THYROID
way of classifying obesity in adults according to GLAND, DISEASES OF), HYPOPITUITARISM,
severity. For example: HYPOGONADISM or CUSHINGS SYNDROME.

Grade of obesity
Symptoms Obesity has adverse effects on
BMI (W/H2) MORBIDITY and mortality (see DEATH RATE)
III >40 which are greatest in young adults and increase
II 3040 with the severity of obesity. It is associated with
I 25299 an increased mortality and/or morbidity from
not obese <25 cardiovascular disease, non-insulin-dependent
diabetes mellitus, diseases of the gall-bladder,
Causes Whatever the causes of obesity, the osteoarthritis, hernia, gout and possibly certain
fact remains that energy intake (in the form of cancers (i.e. colon, rectum and prostate in men,
food and drink) must exceed energy output and breast, ovary, endometrium and cervix in
(in the form of activity and exercise) over a suf- women). Menstrual irregularities and ovulatory
ficiently long period of time. failure are often experienced by obese women.
Obesity tends to aggregate in families. This Obese people are also at greater risk when they
has led to the suggestion that some people undergo surgery. With the exception of gall-
inherit a thrifty gene which predisposes them stone formation, weight loss will reduce these
to obesity in later life by lowering their energy health risks.
output. Indeed, patients often attribute their
obesity to such a metabolic defect. Total energy Treatment Creation of an energy deficit is
output is made up of the resting metabolic rate essential for weight loss to occur, so the initial
(RMR), which represents about 70 per cent of line of treatment is a slimming diet. An average
the total; the energy cost of physical activity; deficit of 1,000 kcal/day (see CALORIE) will pro-
and thermogenesis, i.e. the increase in energy duce a loss of 1 kg of fat/week and should be
output in response to food intake, cold aimed for. Theoretically, this can be achieved by
exposure, some drugs and psychological influ- increasing energy expenditure or reducing
ences. In general, obese people are consistently energy intake. In practice, a low-energy diet is
found to have a higher RMR and total energy the usual form of treatment since attempts to
 Occupational Health, Medicine and Diseases 505

increase energy expenditure, either by physical by sensitive and appropriate treatment, is vital.
exercise or a thermogenic drug, are relatively Doctors and nurses can specialise in obstetrics
ineffective. after suitable training. (See also PREGNANCY AND
Anorectic drugs, gastric stapling and jaw- LABOUR.)
wiring are sometimes used to treat severe obes-
ity. They are said to aid compliance with a Obstipation
low-energy diet by either reducing hunger Severe CONSTIPATION.
(anorectic drugs) or limiting the amount of
food the patient can eat. Unfortunately, the Obstruction of the Bowels
long-term effectiveness of gastric stapling is not See under INTESTINE, DISEASES OF.
known, and it is debatable whether the modest
reduction in weight achieved by use of anorectic Occiput
drugs is worthwhile although a new drug, The lower and hinder part of the head, where it
ORLISTAT, is becoming available that reduces merges into the neck.
the amount of fat absorbed from food in the
gastrointestinal tract. For some grossly obese Occlusion
patients, jaw-wiring can be helpful, but a regain The way that the TEETH fit together when the
of weight once the wires are removed must be jaws close. Also the closing or obstruction of a
prevented. These procedures carry a risk, so duct, hollow organ, or blood vessel.
should be done only if an individuals health is
in danger. Occult
Describing something that is not easily seen.
Obsessive Compulsive Disorder Occult blood in the faeces is present in very
A mental-health problem which will be experi- small amounts and can be identified only by a
enced at some time by up to 3 per cent of chemical test or under the microscope.
adults. The main feature is the occurrence of
spontaneous intrusive thoughts that cause Occupational Health, Medicine
intense anxiety. Many of these thoughts prompt and Diseases
urges, or compulsions, to carry out particular
actions in order to reduce the anxiety. One of Occupational health The effect of work
the commonest obsessions is a fear of dirt and on human health, and the impact of workers
contamination that prompts compulsive clean- health on their work. Although the term
ing or repeated and unnecessary handwashing. encompasses the identification and treatment of O
(See MENTAL ILLNESS.) specific occupational diseases, occupational
health is also an applied and multidisciplinary
Obstetrics subject concerned with the prevention of
The branch of medicine dealing with preg- occupational ill-health caused by chemical, bio-
nancy and giving birth. Derived from the Latin logical, physical and psychosocial factors, and
word for midwifery (see MIDWIFE), it is closely the promotion of a healthy and productive
allied to GYNAECOLOGY. It is concerned with workforce.
the health of the woman and fetus, from early Occupational health includes both mental
in pregnancy through to a successful labour and and physical health. It is about compliance with
delivery. Pregnancy and childbirth are, however, health-and-safety-at-work legislation (and
normal physiological events and for most common law duties) and about best practice in
women they take place without complications. providing work environments that reduce risks
Nevertheless, if something does go wrong, to health and safety to lowest practicable levels.
skilled medical care should be immediately It includes workers fitness to work, as well as
available to help the mother and baby achieve a the management of the work environment to
successful outcome. Routine monitoring of accommodate people with disabilities, and pro-
pregnancies by midwives and, where necessary, cedures to facilitate the return to work of those
general practitioners or obstetricians is well absent with long-term illness. Occupational
recognised as a significant contribution to a health incorporates several professional groups,
successful pregnancy and delivery. Such moni- including occupational physicians, occu-
toring has been greatly facilitated by advances pational health nurses, occupational hygienists,
in ULTRASOUND, AMNIOSCOPY, and amnio- ergonomists, disability managers, workplace
and cordocentesis (see PRENATAL SCREENING OR counsellors, health-and-safety practitioners,
DIAGNOSIS). Numerous problems may occur at and workplace physiotherapists.
all stages, and early detection, followed rapidly In the UK, two key statutes provide a
 506 Occupational Health, Medicine and Diseases

framework for occupational health: the Health the need for the working population to achieve
and Safety at Work, etc. Act 1974 (HSW Act); a work-life balance and the promotion of this
and the Disability Discrimination Act 1995 is an increasing part of occupational health
(DDA). The HSW Act states that employers strategies.
have a duty to protect the health, safety and The law requires employers to consult with
welfare of their employees and to conduct their their staff on health-and-safety matters. How-
business in a way that does not expose others to ever, there is also a growing understanding that
risks to their health and safety. Employees and successful occupational-health management
self-employed people also have duties under the involves workers directly in the identification of
Act. Modern health-and-safety legislation risks and in developing solutions in the work-
focuses on assessing and controlling risk rather place. Trade unions play an active role in pro-
than prescribing specific actions in different moting occupational health through local and
industrial settings. Various regulations made national campaigns and by training and advis-
under the HSW Act, such as the Control of ing elected workplace safety representatives.
Substances Hazardous to Health Regulations,
the Manual Handling Operations Regulations Occupational medicine The branch of
and the Noise at Work Regulations, set out medicine that deals with the control, preven-
duties with regard to different risks, but apply tion, diagnosis, treatment and management of
to all employers and follow the general prin- ill-health and injuries caused or made worse by
ciples of risk assessment and control. Risks work, and with ensuring that workers are fit for
should be controlled principally by removing or the work they do.
reducing the hazard at source (for example, by Occupational medicine includes: statutory
substituting chemicals with safer alternatives, surveillance of workers exposure to hazardous
replacing noisy machinery, or automating tasks agents; advice to employers and employees on
to avoid heavy lifting). Personal protective eliminating or reducing risks to health and
equipment, such as gloves and ear defenders, safety at work; diagnosis and treatment/man-
should be seen as a last line of defence after agement of occupational illness; advice on
other control measures have been put in place. adapting the working environment to suit the
The employment provisions of the DDA worker, particularly those with disabilities or
require employers to avoid discriminatory prac- long-term health problems; and advice on the
tice towards disabled people and to make rea- return to work and, if necessary, rehabilitation
sonable adjustments to working arrangements of workers absent through illness. Occupational
O where a disabled person is placed at a substan- physicians may play a wider role in monitoring
tial disadvantage to a non-disabled person. the health of workplace populations and in
Although the DDA does not require employers advising employers on controlling health haz-
to provide access to rehabilitation services ards where ill-health trends are observed. They
even for those injured or made ill at work may also conduct epidemiological research (see
occupational-health practitioners may become EPIDEMIOLOGY) on workplace diseases.
involved in programmes to help people get back Because of the occupational physicians dual
to work after injury or long-term illness, and role as adviser to both employer and employee,
many businesses see the retention of valuable he or she is required to be particularly diligent
staff as an attractive alternative to medical with regards to the individual workers medical
retirement or dismissal on health grounds. CONFIDENTIALITY. Occupational physicians
Although a major part of occupational- need to recognise in any given situation the
health practice is concerned with statutory context they are working in, and to make sure
compliance, the workplace is also an important that all parties are aware of this.
venue for health promotion. Many working Occupational medicine is a medical discip-
people rarely see their general practitioner and, line and thus is only part of the broader
even when they do, there is little time to discuss field of occupational health. Although there
wider health issues. Occupational-health are some specific clinical duties associated
advisers can fill in this gap by providing, for with occupational medicine, such as diagnosis
example, workplace initiatives on stopping of occupational disease and medical screening,
smoking, cardiovascular health, diet and self- occupational physicians are frequently part of a
examination for breast and testicular cancers. multidisciplinary team that might include, for
Such initiatives are encouraged because of the example, occupational-health nurses, health-
perceived benefits to staff, to the employing and-safety advisers, ergonomists, counsellors
organisation and to the wider public-health and hygienists. Occupational physicians are
agenda. Occupational psychologists recognise medical practitioners with a post-registration
 Occupational Health, Medicine and Diseases 507

qualification in occupational medicine. They (ODIN) and from the Labour Force Survey
will have completed a period of supervised (LFS). ODIN data is generated by the system-
in-post training. In the UK, the Faculty of atic reporting of work-related conditions by
Occupational Medicine of the Royal College of clinicians and includes several schemes. Under
Physicians has three categories of membership, one scheme, more than 80 per cent of all
depending on qualifications and experience: reported diseases by occupational-health phys-
associateship (AFOM); membership (MFOM); icians fall into just six of the 42 clinical disease
and fellowship (FFOM). categories: upper-limb disorders; anxiety,
depression and stress disorders; contact DERMA-
Occupational diseases Occupational dis- TITIS; lower-back problems; hearing loss (see
eases are illnesses that are caused or made worse DEAFNESS); and ASTHMA. Information from the
by work. In their widest sense, they include LFS yields a similar pattern in terms of disease
physical and mental ill-health conditions. frequency. Its most recent survey found that
In diagnosing an occupational disease, the over 2 million people believed that, in the pre-
clinician will need to examine not just the signs vious 12 months, they had suffered from an
and symptoms of ill-health, but also the occu- illness caused or made worse by work and that
pational history of the patient. This is import- 19.5 million working days were lost as a result.
ant not only in discovering the cause, or causes, The ten most frequently reported disease
of the disease (work may be one of a number of categories were:
factors), but also in making recommendations
on how the work should be modified to prevent
stress and mental ill-health (see MENTAL ILL-
NESS): 515,000 cases.
a recurrence or, if necessary, in deciding back injuries: 508,000.
whether or not the worker is able to return to upper-limb and neck disorders: 375,000.
that type of work. The occupational history will lower respiratory disease: 202,000.
help in deciding whether or not other workers
are also at risk of developing the condition. It
deafness, TINNITUS or other ear conditions:
170,000.
will include information on: lower-limb musculoskeletal conditions:
the nature of the work. 100,000.
how the tasks are performed in practice. skin disease: 66,000.
the likelihood of exposure to hazardous headache or eyestrain: 50,000.
agents (physical, chemical, biological and traumatic injury (includes wounds and frac-
psychosocial). tures from violent attacks at work): 34,000.
what control measures are in place and the
extent to which these are adhered to.
vibration white finger (hand-arm vibration
syndrome): 36,000.
O
previous occupational and non-occupational
exposures.
A person who develops a chronic occu-
pational disease may be able to sue his or her
whether or not others have reported similar employer for damages if it can be shown that
symptoms in relation to the work. the employer was negligent in failing to take
Some conditions certain skin conditions, reasonable care of its employees, or had failed to
for example may show a close relationship to provide a system of work that would have pre-
work, with symptoms appearing directly only vented harmful exposure to a known health
after exposure to particular agents or possibly hazard. There have been numerous successful
disappearing at weekends or with time away claims (either awarded in court, or settled out of
from work. Others, however, may be chronic court) for damages for back and other musculo-
and can have serious long-term implications for skeletal injuries, hand-arm vibration syndrome,
a persons future health and employment. noise-induced deafness, asthma, dermatitis,
Statistical information on the prevalence of MESOTHELIOMA and ASBESTOSIS. Employers
occupational disease in the UK comes from a liability (workers compensation) insurers are
variety of sources, including official figures predicting that the biggest future rise in dam-
from the Industrial Injuries Scheme (see below) ages claims will be for stress-related illness. In a
and statutory reporting of occupational disease recent study, funded by the Health and Safety
(also below). Neither of these official schemes Executive, about 20 per cent of all workers
provides a representative picture, because the more than 5 million people in the UK
former is restricted to certain prescribed condi- claimed to be very or extremely stressed at
tions and occupations, and the latter suffers work a statistic that is likely to have a major
from gross under-reporting. More useful are impact on the long-term health of the working
data from the various schemes that make up the population.
Occupational Diseases Intelligence Network While victims of occupational disease have
 508 Occupational Health, Medicine and Diseases

the right to sue their employers for damages, for example, cardiovascular disease and cancers
many countries also operate a system of no- where the causes are multifactorial. The toll
fault compensation for the victims of prescribed would, however, dwarf the number of deaths
occupational diseases. In the UK, more than 60 caused by accidents at work. Around 250
diseases are prescribed under the Industrial people are killed by accidents at work in the UK
Injuries Scheme and a person will automatically each year mesothelioma, from exposure to
be entitled to state compensation for disability asbestos at work, alone kills more than 1,300
connected to one of these conditions, provided people annually.
that he or she works in one of the occupations The following is a sample list of occupational
for which they are prescribed. The following diseases, with brief descriptions of their
short list gives an indication of the types of dis- aetiologies.
eases and occupations prescribed under the
scheme: Inhaled materials
CARPAL TUNNEL SYNDROME connected to
the use of hand-held vibrating tools.
PNEUMOCONIOSIS covers a group of diseases
which cause fibrotic lung disease following the
hearing loss from (amongst others) use of
pneumatic percussive tools and chainsaws,
inhalation of dust. Around 250300 new cases
receive benefit each year mostly due to coal
working in the vicinity of textile manufactur- dust with or without silica contamination. SILI-
ing or woodworking machines, and work in COSIS is the more severe disease. The contrac-
ships engine rooms. tion in the size of the coal-mining industry as
LEPTOSPIROSIS infection with Leptospira well as improved dust suppression in the mines
(various listed occupations). have diminished the importance of this disease,
viral HEPATITIS from contact with human
blood, blood products or other sources of
whereas asbestos-related diseases now exceed
1,000 per year. Asbestos fibres cause a restrictive
viral hepatitis. lung disease but also are responsible for certain
LEAD POISONING, from any occupation caus-
ing exposure to fumes, dust and vapour from
malignant conditions such as pleural and peri-
toneal mesothelioma and lung cancer. The
lead or lead products. lung-cancer risk is exacerbated by cigarette-
asthma caused by exposure to, among other
listed substances, isocyanates, curing agents,
smoking.
Even though the use of asbestos is virtually
solder flux fumes and insects reared for banned in the UK, many workers remain at risk
research. of exposure because of the vast quantities pres-
O mesothelioma from exposure to asbestos.
In the UK, employers and the self-employed
ent in buildings (much of which is not listed in
building plans). Carpenters, electricians,
have a duty to report all occupational injuries plumbers, builders and demolition workers are
(if the employee is off work for three days or all liable to exposure from work that disturbs
more as a result), diseases or dangerous inci- existing asbestos.
dents to the relevant enforcing authority (the OCCUPATIONAL ASTHMA is of increasing
Health and Safety Executive or local-authority importance not only because of the recogni-
environmental-health department) under the tion of new allergic agents (see ALLERGY), but
Reporting of Injuries, Diseases and Dangerous also in the number of reported cases. The fol-
Occurrences Regulations 1995 (RIDDOR). lowing eight substances are most frequently
Despite this statutory duty, comparatively few linked to occupational asthma (key occupations
diseases are reported so that figures generated in brackets): isocyanates (spray painters,
from RIDDOR reports do not give a useful electrical processors); flour and grain (bakers
indication of the scale of occupational diseases and farmers); wood dust (wood workers); glu-
in the UK. The statutory reporting of injuries is taraldehyde (nurses, darkroom technicians);
much better, presumably because of the clear solder/colophony (welders, electronic assembly
and acute relationship between a workplace workers); laboratory animals (technicians, sci-
accident and the resultant injury. More than entists); resins and glues (metal and electrical
160,000 injuries are reported under RIDDOR workers, construction, chemical processors);
every year compared with just 2,500 or so and latex (nurses, auxiliaries, laboratory
occupational diseases, a gross underestimate of technicians).
the true figure. The disease develops after a short, symptom-
There are no precise figures for the number less period of exposure; symptoms are tempor-
of people who die prematurely because of work- ally related to work exposures and relieved by
related ill-health, and it would be impossible to absences from work. Removal of the worker
gauge the exact contribution that work has on, from exposure does not necessarily lead to
 Occupational Health, Medicine and Diseases 509

complete cessation of symptoms. For many carpal tunnel syndrome irrespective of work)
agents, there is no relationship with a previous and clinicians need to be careful when assigning
history of ATOPY. Occupational asthma work as the cause without first considering the
accounts for about 10 per cent of all asthma evidence. Other conditions may be revealed or
cases. made worse by work such as OSTEOARTHRITIS
DERMATITIS The risk of dermatitis caused by in the hand. Much attention has focused on
an allergic or irritant reaction to substances injuries caused by repeated movement, exces-
used or handled at work is present in a wide sive force, and awkward postures and these
variety of jobs. About three-quarters of cases are include tenosynovitis (inflammation of a ten-
irritant contact dermatitis due to such agents as don) and epicondylitis. The greatest contro-
acids, alkalis and solvents. Allergic contact versy surrounds upper-limb disorders that do
dermatitis is a more specific response by suscep- not present obvious tissue or nerve damage but
tible individuals to a range of allergens (see nevertheless give significant pain and dis-
ALLERGEN). The main occupational contact comfort to the individual. These are sometimes
allergens include chromates, nickel, epoxy referred to as repetitive strain injury or diffuse
resins, rubber additives, germicidal agents, dyes, RSI. The diagnosis of such conditions is con-
topical anaesthetics and antibiotics as well as troversial, making it difficult for sufferers to
certain plants and woods. Latex gloves are a par- pursue claims for compensation through the
ticular cause of occupational dermatitis among courts. Psychosocial factors, such as high
health-care and laboratory staff and have demands of the job, lack of control and poor
resulted in many workers being forced to leave social support at work, have been implicated in
their profession through ill-health. (See also SKIN, the development of many upper-limb disorders,
DISEASES OF.) and in prevention and management it is
important to deal with the psychological as well
Musculoskeletal disorders Musculoskel- as the physical risk factors. Occupations known
etal injuries are by far the most common condi- to be at particular risk of work-related upper-
tions related to work (see LFS figures, above) limb disorders include poultry processors,
and the biggest cause of disability. Although not packers, electronic assembly workers, data pro-
all work-related, musculoskeletal disorders cessors, supermarket check-out operators and
account for 36.5 per cent of all disabilities telephonists. These jobs often contain a num-
among working-age people (compared with less ber of the relevant exposures of dynamic load,
than 4 per cent for sight and hearing impair- static load, a full or excessive range of move-
ment). Back pain (all causes see BACKACHE) ments and awkward postures. (See UPPER LIMB O
has been estimated to cause more than 50 mil- DISORDERS.)
lion days lost every year in sickness absence and
costs the UK economy up to 5 billion annu- Physical agents A number of physical agents
ally as a result of incapacity or disability. Back cause occupational ill-health of which the most
pain is a particular problem in the health-care important is occupational deafness. Workplace
sector because of the risk of injury from lifting noise exposures in excess of 85 decibels for a
and moving patients. While the emphasis working day are likely to cause damage to hear-
should be on preventing injuries from occur- ing which is initially restricted to the vital fre-
ring, it is now well established that the best way quencies associated with speech around 34
to manage most lower-back injuries is to kHz. Protection from such noise is imperative
encourage the patient to continue as normally as hearing aids do nothing to ameliorate the
as possible and to remain at work, or to return neural damage once it has occurred.
as soon as possible even if the patient has some Hand-arm vibration syndrome is a disorder
residual back pain. Those who remain off work of the vascular and/or neural endings in the
on long-term sick leave are far less likely ever to hands leading to episodic blanching (white fin-
return to work. ger) and numbness which is exacerbated by low
Aside from back injuries, there are a whole temperature. The condition, which is caused by
range of conditions affecting the upper limbs, vibrating tools such as chain saws and pneu-
neck and lower limbs. Some have clear aetiolo- matic hammers, is akin to RAYNAUDS DISEASE
gies and clinical signs, while others are less well and can be disabling.
defined and have multiple causation. Some Decompression sickness is caused by a rapid
conditions, such as carpal tunnel syndrome, are change in ambient pressure and is a disease
prescribed diseases in certain occupations; how- associated with deep-sea divers, tunnel workers
ever, they are not always caused by work (preg- and high-flying aviators. Apart from the direct
nant and older women are more likely to report effects of pressure change such as ruptured
 510 Occupational Health, Medicine and Diseases

tympanic membrane or sinus pain, the more mals to humans), such as ANTHRAX, Borrelia
serious damage is indirectly due to nitrogen burgdorferi (LYME DISEASE), bovine TUBERCU-
bubbles appearing in the blood and blocking LOSIS, BRUCELLOSIS, Chlamydia psittaci, lepto-
small vessels. Central and peripheral nervous- spirosis, ORF virus, Q fever, RINGWORM and
system damage and bone necrosis are the most Streptococcus suis. Human pathogens that may
dangerous sequelae. be transmissible at work include tuberculosis,
and blood-borne pathogens such as viral hepa-
Radiation Non-ionising radiation from titis (B and C) and HIV (see AIDS/HIV). Health-
lasers or microwaves can cause severe localised care workers at risk of exposure to infected
heating leading to tissue damage of which blood and body fluids should be immunised
cataracts (see under EYE, DISORDERS OF) are a against hapatitis B.
particular variety. Ionising radiation from
radioactive sources can cause similar acute Poisoning The incidence of occupational
tissue damage to the eyes as well as cell damage poisonings has diminished with the substitu-
to rapidly dividing cells in the gut and bone tion of noxious chemicals with safer alterna-
marrow. Longer-term effects include genetic tives, and with the advent of improved
damage and various malignant disorders of containment. However, poisonings owing to
which LEUKAEMIA and aplastic ANAEMIA are accidents at work are still reported, sometimes
notable. Particular radioactive isotopes may with fatal consequences. Workers involved in
destroy or induce malignant change in target the application of pesticides are particularly at
organs, for example, 131I (thyroid), 90Sr (bone). risk if safe procedures are not followed or if
Outdoor workers may also be at risk of sunburn equipment is faulty. Exposure to organo-
and skin cancers. phosphate pesticides, for example, can lead to
OTHER OCCUPATIONAL CANCERS Occupation breathing difficulties, vomiting, diarrhoea and
is directly responsible for about 5 per cent of all abdominal cramps, and to other neurological
cancers and contributes to a further 5 per cent. effects including confusion and dizziness.
Apart from the cancers caused by asbestos and Severe poisonings can lead to death. Exposure
ionising radiation, a number of other occu- can be through ingestion, inhalation and
pational exposures can cause human cancer. dermal (skin) contact.
The International Agency for Research on Can-
cer regularly reviews the evidence for carcino- Stress and mental health Stress is an
genicity of compounds and industrial processes, adverse reaction to excessive pressures or
O and its published list of carcinogens is widely demands and, in occupational-health terms, is
accepted as the current state of knowledge. different from the motivational impact often
More than 50 agents and processes are listed as associated with challenging work (some refer to
class 1 carcinogens. Important occupational this as positive stress). Stress at work is often
carcinogens include asbestos (mesothelioma, linked to increasing demands on workers,
lung cancer); polynuclear aromatic hydro- although coping can often prevent the devel-
carbons such as mineral oils, soots, tars (skin opment of stress. The causes of occupational
and lung cancer); the aromatic amines in dye- stress are multivariate and encompass job char-
stuffs (bladder cancer); certain hexavalent acteristics (e.g. long or unsocial working hours,
chromates, arsenic and nickel refining (lung high work demands, imbalance between effort
cancer); wood and leather dust (nasal sinus can- and reward, poorly managed organisational
cer); benzene (leukaemia); and vinyl chloride change, lack of control over work, poor social
monomer (angiosarcoma of the liver). It has support at work, fear of redundancy and bully-
been estimated that elimination of all known ing), as well as individual factors (such as per-
occupational carcinogens, if possible, would sonality type, personal circumstances, coping
lead to an annual saving of 5,000 premature strategies, and availability of psychosocial sup-
deaths in Britain. port outside work). Stress may influence
behaviours such as smoking, alcohol consump-
Infections Two broad categories of job carry tion, sleep and diet, which may in turn affect
an occupational risk. These are workers in con- peoples health. Stress may also have direct
tact with animals (farmers, veterinary surgeons effects on the immune system (see IMMUNITY)
and slaughtermen) and those in contact with and lead to a decline in health. Stress may also
human sources of infection (health-care staff alter the course and response to treatment of
and sewage workers). conditions such as cardiovascular disease. As
Occupational infections include various well as these general effects of stress, specific
zoonoses (pathogens transmissible from ani- types of disorder may be observed.
 Oedema of the Lungs 511

Exposure to extremely traumatic incidents at followed. The course lasts three academic
work such as dealing with a major accident years. (See also APPENDIX 8: PROFESSIONAL
involving multiple loss of life and serious injury ORGANISATIONS.)
(e.g. paramedics at the scene of an explosion or
rail crash) may result in a chronic condition Ochronosis
known as post-traumatic stress disorder A rare condition in which the ligaments and
(PTSD). PTSD is an abnormal psychological cartilages of the body, and sometimes the con-
reaction to a traumatic event and is character- junctiva (see EYE), become stained by dark
ised by extreme psychological discomfort, such brown or black pigment. This may occur in
as anxiety or panic when reminded of the causa- chronic carbolic poisoning, or in a congenital
tive event; sufferers may be plagued with disorder of metabolism in which the individual
uncontrollable memories and can feel as if they is unable to break down completely the tyrosine
are going through the trauma again. PTSD is a of the protein molecule the intermediate
clinically defined condition in terms of its product, homogentisic acid, appearing in the
symptoms and causes and should not be used to urine, this being known as alkaptonuria.
include normal short-term reactions to trauma.
Oedema
Occupational Therapy An abnormal accumulation of fluid beneath the
The treatment of physical and psychiatric con- skin, or in one or more of the cavities of
ditions through specific selected activities in the body.
order to help people reach their maximum level
of function and independence in all aspects of Causes Oedema is not a disease, it is a sign
daily life. usually of underlying local or systemic disease.
Occupational therapists work from hospital It may sometimes be visible as a swelling.
and community bases. They do much more Oedema occurs when the normal mechanisms
than keep patients occupied with diverting for maintaining a balance between fluid in the
hobbies. The arts and crafts still have a place in tissues and in the blood are upset. That balance
modern therapy techniques, but these now also depends mainly on the blood pressure that
include household chores, industrial work, keeps the blood flowing through the circulatory
communication techniques, social activities, system thus forcing fluid out of the capillaries
sports and educational programmes. An and the osmotic drawing force of the blood
occupational therapy department may have proteins which pulls water into the blood-
facilities for woodwork, metalwork, printing, stream. The KIDNEYS also have an essential role O
gardening, cooking, art and drama. Occu- in maintaining this balance.
pational therapists will use any combination of Among the disorders that may disturb this
activities to strengthen muscles, increase balance are heart failure, NEPHROTIC SYN-
movement and restore coordination and bal- DROME, kidney failure, CIRRHOSIS of the liver
ance. With mentally ill people, similar activies and a diet deficient in protein. Injury may also
are used. They help provide order, comfort and cause oedema and ascites (fluid in the abdom-
support and aim to build up self-confidence. inal cavity) can occur as a result of cirrhosis of
Occupational therapists plan courses of treat- the liver or cancer in the abdominal organs.
ment which are individually tailored to the
needs of the patient. The aim is to help the Treatment The underlying cause of oedema
patient practise all the activites involved in daily should be treated and, if this is not feasible or
life. (See REHABILITATION.) effective, the excess fluid should be excreted by
The therapists are part of a team including boosting the output of the kidney. Restriction
doctors, nurses, social workers, home helps, of sodium in the diet and the administration of
housing officers, physiotherapists, speech ther- DIURETICS are effective methods of achieving
apists and psychologists. Occupational therap- this.
ists are mainly employed by the National
Health Service and by local-authority social ser- Oedema of the Lungs
vices, and they work in hospitals, special centres This occurs as a result of left ventricular failure
and in the handicapped persons own home. (see HEART, DISEASES OF). There is an abrupt
State registration is essential for employment as increase in the venous and capillary pressure in
an occupational therapist. There are 15 occu- the pulmonary vessels, followed by flooding of
pational therapy schools in the United King- fluid into the interstitial spaces and alveoli. The
dom where the course leading to the diploma of commonest cause of acute pulmonary oedema
the College of Occupational Therapists can be is myocardial infarction (see HEART, DISEASES
 512 Oedipus Complex

OF) which reduces the ability of the left ven- muscles of the lower part of the oesophagus do
tricular myocardial muscle to handle the blood not work properly (ACHALASIA), allowing the
delivered to it. Pulmonary oedema may result stomachs acidic contents to regurgitate (reflux
from other causes of left ventricular failure such oesophagitis). HIATUS HERNIA is sometimes
as HYPERTENSION or valvular disease of the associated with the latter condition. Diagnosis
mitral and aortic valves. The initial symptoms can be made by ENDOSCOPY of the oesophagus
are cough with breathlessness and occasionally and/or an X-ray examination using a barium
with wheezing (once called cardiac asthma). swallow. Treatment of reflux oesophagitis is by
The patient becomes extremely short of breath an appropriate diet and weight loss. Stricture of
and in a severe attack the patient is pale, sweat- the oesophagus can result from swallowing a
ing and cyanosed and obviously gasping for corrosive fluid and may produce severe narrow-
breath. Frequently, frothy sputum is produced ing. Such strictures may sometimes be dilated
which may be blood-stained. Treatment is with by the use of suitable instruments; otherwise,
DIURETICS and measures to deal with the myo- surgery may be necessary.
cardial infarction or other underlying cause. A still more serious and frequent cause of
oesophageal stricture is that due to cancer,
Oedipus Complex which may occur at any part, but is most com-
A description used by psychoanalysts of the mon at the lower end, near the entrance into
subconscious attraction of a child for its parent the stomach. The chief symptoms of this condi-
of the opposite sex. This is accompanied by a tion are increasing difficulty in swallowing,
wish to get rid of the parent of the same sex. increasing debility, together with enlargement
The origin of the phrase lies in the Greek story of the glands in the neck. The condition usually
in which Oedipus kills his father without realis- occurs in middle age or beyond and around
ing who he is, then marries his mother. It has 5,000 people are diagnosed with such cancer
been suggested that the arrest of psychological every year in the United Kingdom. In many
development at the Oedipal stage may cause cases treatment can only be palliative, but
NEUROSIS and sexual dysfunction. recent advances in surgery are producing prom-
ising results. In some cases treatment with
Oesophagoscope irradiation or anti-cancer drugs produces relief,
An endoscopic instrument for observing the if not cure. In those in whom neither operation
lining of the OESOPHAGUS. (See ENDOSCOPE.) nor radiation can be performed, life may be
prolonged and freedom from pain obtained by
O Oesophagostomy fluid food which is either swallowed or passed
A surgical operation in which the OESOPHAGUS down a tube. In cases of achalasia (see above),
is opened on to the surface of the neck. The the passage of a special bougie down the
procedure is usually carried out as a temporary oesophagus to dilate the sphincter may be
measure to facilitate feeding and drinking after effective.
an operation on the throat. Strictures of the oesophagus may also be
produced by the pressure of tumours or
Oesophagus aneurysms within the cavity of the chest but
The oesophagus, or gullet, is the muscular tube external to the gullet.
linking the throat to the stomach, down which Finally, difficulty in swallowing sometimes
passes swallowed food and drink. It consists of occurs in certain serious nervous diseases from
three coats: a strong outer coat of muscle-fibres paralysis affecting the nerves supplying the
in two layers, the outer running lengthwise, the muscular coats of the PHARYNX, which thus
inner being circular; inside this a loose connect- loses its propulsive power (bulbar paralysis).
ive tissue coat containing blood vessels, glands, Foreign bodies which lodge in the respiratory
and nerves; and finally a strong mucous mem- part of the throat i.e. at the entrance to, or in
brane lined by epithelium, which closely the cavity of, the larynx set up immediate
resembles that of the mouth and skin. Peri- symptoms of CHOKING. Those which lodge in
staltic waves (see PERISTALSIS) and mucus secre- the gullet, on the contrary, do not usually set up
tion from the lining cells help the passage of any immediately serious symptoms, although
food. their presence causes considerable discomfort.
Medical attention is usually required.
Oesophagus, Diseases of
Oesophagitis is inflammation of the OESOPH- Oestradiol
AGUS and may be due to swallowing a corrosive The name given to the oestrogenic hormone (see
chemical (corrosive oesophagitis) or because the OESTROGENS) secreted by the ovarian follicle.
 Olfactory Nerves 513

Oestradiol is responsible for the development of Oestrone

the female sexual characteristics, of the See OESTROGENS.
BREASTS, and of part of the changes that take
place in the UTERUS before MENSTRUATION. Office for National Statistics
(ONS)
Oestradiol Valerate This is an executive agency of the UK govern-
See OESTROGENS. ment formed by an amalgamation in 1990 of
the Central Statistical Office and the Office of
Oestriol Population Censuses and Surveys (OPCS). The
See OESTROGENS. ONS compiles and publishes statistics on
national and local populations, including their
Oestrogen Receptor social and economic situation and contribu-
A site on the membrane surrounding a cell (see tions to the countrys economy. It also records
CELLS) that binds to the hormone OESTRO- the demographic patterns of births, marriages
GENS. This activates the cells reaction to the and deaths, including the medical cause of
hormone. Anti-oestrogen drugs such as TAM- death. The former OPCS organised a national
OXIFEN used to treat breast cancer (see BREASTS, ten-yearly census and ONS is carrying on this
DISEASES OF) prevent the oestrogen from activity. The census is based on the actual pres-
binding to these receptors. ence of individuals in a house or institutions on
a given night. The figures provide government
Oestrogens departments and local authorities with infor-
Natural or synthetic substances that induce mation for planning services.
the changes in the UTERUS that precede OVU-
LATION. They are also responsible for the Ofloxacin
development of the secondary sex character- A quinolone drug (see QUINOLONES) used to
istics in women: that is, the physical changes treat infections in the urinary, respiratory and
that take place in a girl at puberty, such as reproductive tracts.
enlargement of the BREASTS, appearance of
pubic and axillary hair, and the deposition of Ointments
fat on the thighs and hips. They are used in Semi-solid, greasy substances used as EMOL-
the management of disturbances of the LIENTS, protectants and as vehicles for topical
MENOPAUSE, and also in the treatment of can- drug delivery, ointments may be hydrophilic or
cer of the prostate (see PROSTATE GLAND, DIS- hydrophobic. The former dissolve in water and O
EASES OF) and certain cases of cancer of the usually contain polyethylene glycols. Hydro-
breast. phobic ointments do not combine with water
The oestrogenic hormones of the ovary are and are paraffin-based. Mixing hard and soft
OESTRADIOL and oestrone. The rapid deg- paraffins allows stiffness and greasiness to be
radation of natural oestrogens limits their use as modified. Pastes are ointments containing a
therapeutic agents. Chemical substitution of high proportion of inert powder such as starch
the steroid molecule, as in ethinyl oestradiol, or or zinc oxide which confers stiffness. Pastes are
the use of a non-steroidal synthetic oestrogen protective and allow precise aplication of drugs
such as STILBOESTROL, greatly reduces the rate to the skin.
of degradation and enhances the therapeutic
action. A further development has been the use Old Age
of compounds which are not actually oestro- See AGEING.
genic themselves, but which are slowly metab-
olised to oestrogenic substances, or substances Olecranon Process
such as chlorotrianisene, which are taken up in The large process on the ulnar bone that pro-
the body fat and then slowly released into the jects behind the joint of the elbow.
circulation. There is in fact little to choose
between the various synthetic oestrogens. Oleic Acid
Ethinyl oestradiol is the most potent oral oes- The most common of naturally occurring fatty
trogen, being 20 times more active than acids, being present in most fats and oils in the
stilboestrol. form of triglyceride. It is used in the prepar-
Other commonly used oestrogen drugs are ation of OINTMENTS, but not eye ointments.
dienoestrol and oestrol. The use of oestrogens
in hormone replacement therapy (HRT) is Olfactory Nerves
dealt with in the entry on the MENOPAUSE. The nerves of SMELL. Each nerve detects smell
 514 Oligaemia

by means of hair-like receptors positioned in inflammatory erosion of the oesophagus (see

the mucous membrane lining the roof of the OESOPHAGUS, DISEASES OF).
nasal cavity (see NOSE).
Omphalocele
Oligaemia Another name for exomphalos a HERNIA of
A diminution of the quantity of blood in the abdominal organs through the UMBILICUS.
circulation.
Onchocerciasis
Olig(o)- Infestation with the filarial worm, Onchocerca
A prefix which means little or scanty: for volvulus, found in many parts of tropical Africa,
example, oliguria, excretion of smaller than in Central and South America, and in the
normal quantities of urine. Yemen and Saudi Arabia. After a period of 918
months, the young filarial worms, injected into
Oligomenorrhoea the body by the bite of an infected simulium
Infrequent MENSTRUATION. gnat, mature, mate and start producing young
microfilariae. The females live for up to 15
Oligospermia years and during this period each may produce
A less-than-normal number of sperm (see several thousand microfilariae a day. It is these
SPERMATOZOON) present in each unit volume microfilariae, which have a life-span of up to
of seminal fluid (each ml of semen usually con- two years, that produce the characteristic fea-
tains 20 million sperm). The condition may be tures of the disease: an itching rash of the skin
permanent or temporary and is a major cause of and the appearance of nodules in different parts
INFERTILITY in men. It may be caused by of the body. The worm may invade the optic
ORCHITIS, an undescended testis, or VARICO- nerve of the EYE and so cause blindness; hence
CELE, and should be investigated. the name of African river-blindness. Treatment
consists of diethylcarbamazine and suramin. An
Oliguria international campaign is now underway in an
An abnormally low excretion of URINE, such as attempt to destroy simulium in the affected
occurs in acute NEPHRITIS. zones.

Omentum Oncogenes
A long fold of peritoneal membrane (see PERI- GENES found in mammalian cells and viruses
O TONEUM), generally loaded with more or less that can cause cancer. They are believed to
fat, which hangs down within the cavity of the manufacture the proteins that control the div-
ABDOMEN in front of the bowels. It is formed ision of cells. In certain circumstances this con-
by the layers of peritoneum that cover the front trol malfunctions and a normal cell may be
and back surfaces of the stomach in their pas- changed into one with MALIGNANT properties.
sage from the lower margin of this organ to Extensive research is being done with onco-
cover the back and front surfaces of the large genes with the aim of finding ways to prevent or
intestine. Instead of passing straight from one control cancers.
organ to the other, these layers dip down and
form a sort of fourfold apron. This omentum is Oncologist
known as the greater omentum, to distinguish A doctor who specialises in the treatment of
it from two smaller peritoneal folds, one of cancers (see CANCER; ONCOLOGY). Increasingly,
which passes between the liver and stomach cancer is being treated by multidisciplinary
(the hepatogastric omentum), and the other teams which include surgeons, physicians,
between the liver and duodenum (the hepato- radiotherapists and oncologists. The latter are
duodenal omentum). Together they are known non-surgical cancer specialists and are divided
as the lesser omentum. into clinical and medical branches: clinical
oncologists concentrate mainly on RADIO-
Omeprazole THERAPY treatments; medical oncologists are
This is a proton-pump inhibitor drug (see trained in the medical management of cancer
PROTON-PUMP INHIBITORS) which inhibits patients diagnosing and classifying cancers
gastric-acid secretion by blocking a key enzyme and arranging drug, psychosocial and palliative
system in the parietal cells of the STOMACH. care. The latter claim a pivotal role in liaising
The drug is used to treat (short-term) gastric with primary-care services, clinical oncologists
ulcer (see under STOMACH, DISEASES OF) and and those providing palliative care, as well as
DUODENAL ULCER, as well as strictures and other medical and surgical colleagues involved
 Ocyte 515

in the treatment and care of patients with can- fan); ANTIMETABOLITES (e.g. methotrexate);
cer. With the constant evolution of cancer care VINCA ALKALOIDS (e.g. vincristine, vinblastine);
and the introduction of new treatments such as and antitumour ANTIBIOTICS (e.g. actinomycin
GENE THERAPY, the role of oncologists and their D). Choice of agent and the appropriate
relation with other specialists dealing with can- regimen requires expert guidance. Common
cer will also evolve; but the strategic aim will side-effects include nausea and vomiting, bone-
remain to provide patients with up-to-date, marrow suppression and ALOPECIA, with each
comprehensive, coordinated care in hospitals substance having its own spectrum of unwanted
and the community. effects.
Good doctor-patient communication, with
Oncology the sharing of information and bringing the
The management of MALIGNANT disease a patient into the decision-making process, is
major health problem since successful man- vital even if time-consuming and exhausting.
agement requires close liaison between the Equally imortant treatment is PALLIATIVE, for
patient, surgeons, physicians, oncologists, example to ensure effective pain or nausea con-
haematologists, paediatricians and other spe- trol. Common sources of pain in cancer may
cialists. Diagnosis may involve various investi- involve bone, nerve compression, soft tissue,
gations and often requires a BIOPSY. Once a visceral, myofascial, constipation, muscle
diagnosis has been established, treatment may spasm, low-back pain, joint pain (e.g. capsuli-
involve surgery, radiotherapy or chemotherapy tis) and chronic post-operative pain. Patients
(or various combinations as required) see below, may be suffering from more than one pain, all
and main dictionary entries. of which should be identified. The aim should
be to eliminate pain.
Surgery may be most common, and is often There are three rungs of the analgesic ladder;
the only treatment, for some gastrointestinal if one rung fails, the next one should be tried:
tumours, soft-tissue tumours, gynaecological (1) non-opioid drugs for example, aspirin,
tumours and advanced cancers of the head and PARACETAMOL, NON-STEROIDAL ANTI-
neck. INFLAMMATORY DRUGS (NSAIDS); (2) weak
opioids for example, CODEINE, DIHYDROCO-
Radiotherapy uses ionising radiation to kill DEINE, dextropropoxyphene; (3) strong opioids
tumour cells. Radiation is by naturally occur- for example, MORPHINE, DIAMORPHINE,
ring isotopes (see ISOTOPE) or artificially buprenorphine. Oral treatment is always pref-
produced X-RAYS. Germ-cell tumours (see SEMI- erable, unless prevented by severe vomiting. (See O
NOMA; TERATOMA) and malignant lymphomas also CANCER; ONCOLOGIST; PAIN; PALLIATIVE
(see LYMPHOMA) appear to be particularly sensi- CARE.)
tive to irradiation, and many head and neck
tumours, gynaecological cancers, and localised Onychia
cancers of the PROSTATE GLAND and URINARY Disease of the nails (see SKIN Nail; NAILS, DIS-
BLADDER are curable with radiotherapy. It is EASES OF).
also a valuable means of reducing pain from
bone metastases (see METASTASIS). Unpleasant Onychogryphosis
side-effects are common: chiefly lethargy, loss of A distortion of the nail (see under SKIN) in which
appetite and dry, itchy skin symptoms. it is much thickened, overgrown and twisted on
itself. This usually affects a toe-nail and is the
Chemotherapy is also an important treat- result of chronic irritation and inflammation.
ment in germ-cell tumours (see above); in some
forms of LEUKAEMIA and lymphoma; in ovarian Onycholysis
cancer (following surgery see OVARIES, DIS- Separation of the nail (see under SKIN) from the
EASES OF); and in small-cell lung cancer nail-bed.
(although most patients die within 18 months
see LUNGS, DISEASES OF). It is also used in some Onychomycosis
breast cancers (see BREASTS, DISEASES OF); A fungus infection of the nail (see under SKIN),
advanced myeloma (see MYELOMATOSIS); sar- caused by CANDIDA or DERMATOPHYTES (see also
comas (see under CANCER); and some childhood RINGWORM).
cancers (such as WILMS TUMOUR).
More than 20 substances are in common use, Ocyte
the major classes being ALKYLATING AGENTS An immature OVUM. When the cell undergoes
(e.g. cyclophosphamide, chlorambucil, busul- MEIOSIS in the ovary it becomes an ovum and is
 516 Ogenesis

ready for fertilisation by the spermatozoa. Only Ophthalmology

a small number of the many ocytes produced The study of the structure and function of the
survive until PUBERTY, and not all of them will EYE and the diagnosis and treatment of the dis-
become ova and be ejected into the FALLOPIAN eases that affect it.
TUBES.
Ophthalmoplegia
Ogenesis Paralysis of the muscles of the EYE. Internal
The production of mature egg cells (ova see ophthalmoplegia refers to paralysis of the iris
OVUM) by the OVARIES. Germ cells in the and ciliary body; external ophthalmoplegia
ovary multiply to produce oogonia which refers to paralysis of one or all of the muscles
divide by MEIOSIS to form ocytes in the that move the eyes.
FETUS.
Ophthalmoscope
Ophorectomy An instrument for examining the interior of the
Removal, by operation, of an ovary (see OVAR- EYE. There are different types of ophthalmo-
IES). When the ovary is removed for the pres- scope; all have a light source to illuminate the
ence of a cyst, the term ovariotomy is usually inside of the eye and a magnifying lens to make
employed (see OVARIES, DISEASES OF). examination easier.

Ophoritis Opiate
Another name for ovaritis or inflammation of A preparation of OPIUM.
an ovary (see OVARIES; OVARIES, DISEASES OF).
Opioid
Ophoron A substance with a pharmacological action that
is like that of OPIUM or its derivatives.
Another name for the ovary (see OVARIES).
Opioid Poisoning
Operating Microscope MORPHINE and CODEINE are natural opium
A binocular MICROSCOPE used for MICRO- ALKALOIDS found in the opium poppy (Papaver
SURGERY on, for example, the EYE and middle
somniferum). The other opioids are either syn-
EAR; this microscope is also used for suturing
thetic or semi-synthetic analogues of these.
nerves and blood vessels damaged or severed by Their main use is in the treatment of moderate
O trauma and for rejoining obstructed FALLOPIAN to severe PAIN, but they are also used as antidi-
TUBES in the treatment of INFERTILITY in
arrhoeal and antitussive agents. As a result of
women. induced tolerance (see DEPENDENCE) and great
individual variability, the amount of opioid
Operation substances required to cause serious con-
A surgical procedure using instruments or sequences varies enormously.
sometimes just the hands; for example, when The most common effects of opioid overdose
manipulating a joint or setting a simple frac- are vomiting, drowsiness, pinpoint pupils,
ture. Operations range from simple removal of BRADYCARDIA, CONVULSIONS and COMA.
a small skin lesion under local anaesthetic to a Respiratory depression is common and may
major event such as transplanting a heart which lead to CYANOSIS and respiratory arrest. HYPO-
takes several hours and involves many doctors, TENSION occurs occasionally and in severe cases
nurses and technical staff. Increasingly, oper- non-cardiogenic pulmonary oedema and
ations are done on an outpatient or day-bed cardiovascular collapse may occur. Cardiac
basis, thus enabling many more patients to be ARRHYTHMIA may occur with some opioids.
treated than was the case 25 years ago, and Some opioids have a HISTAMINE-releasing effect
permitting them to resume a normal life often which may result in an urticarial rash (see URTI-
within 24 hours. (See also SURGERY; MINIMALLY CARIA), PRURITUS, flushing and hypotension.
INVASIVE SURGERY (MIS).) Activated CHARCOAL should be given following
overdose and NALOXONE administered to
Ophthalmia reverse respiratory depression and deep coma.
See under EYE, DISORDERS OF.
Opisthotonos
Ophthalmologist The name for a position assumed by the body
A doctor with specialist training in during one of the convulsive seizures of TET-
OPHTHALMOLOGY. ANUS. The muscles of the back, by their
 Oral 517

spasmodic contraction, arch the body in such a Opsonins

way that the person for a time may rest upon Substances present in the SERUM of the blood
the bed only by their heels and head. which act upon bacteria, so as to prepare them
for destruction by the white cells of the blood.
Opium
The dried juice of the unripe seed-capsules of Optic
the white Indian poppy, Papaver somnifer- Concerned with the EYE or vision.
um.The action of opium depends upon the 20
25 ALKALOIDS it contains. Of these, the chief is Optic Atrophy
MORPHINE, the amount of which varies from A deterioration in the fibres of the optic nerve
around 917 per cent. Other alkaloids include (see EYE) resulting in partial or complete loss of
codeine, narcotine, thebaine, papaverine, and vision. It may be caused by damage to the nerve
naceine. from inflammation or injury, or the atrophy
The importation into Britain of opium is may be secondary to disease in the eye.
strictly regulated under the Dangerous Drugs
Acts. Similar regulations govern the sale and Optic Chiasma
distribution of any preparation of morphine or This is formed by a crossing-over of the two
diamorphine (heroin) stronger than 1 part in optic nerves (see EYE) which run from the back
500. (See DEPENDENCE.) of the eyeballs to meet in the mid line beneath
the brain. Nerve fibres from the nasal part of the
Action The action of opium varies consider- retina cross to link up with fibres from the outer
ably, according to the source of the drug and part of the retina of the opposite eye. The linked
the preparation used. nerves form two separate optic tracts which
In small doses, opium produces a state of travel back to the occipital lobes of the brain.
gentle excitement, the person finding their
imagination more vivid, their thoughts more Optic Disc
brilliant, and their power of expression greater Otherwise known as the blind spot of the EYE,
than usual. This stage lasts for some hours, the disc is the beginning of the optic nerve the
and is succeeded by languor. In medicinal point where nerve fibres from the retinas rods
doses this stage of excitement is short and is and cones (the light- and colour-sensitive cells)
followed by deep sleep. When potentially poi- leave the eyeball.
sonous doses are taken, sleep comes on
quickly, and passes into coma and death (see Optician O
OPIOID POISONING). The habitual use of Someone who fits and sells glasses or contact
opium produces great TOLERANCE, so that lenses. An ophthalmic optician (optometrist) is
opium users require to take large quantities trained to perform eye examinations to test for
daily before experiencing its pleasurable long- and short-sightedness and to prescribe
effects. The need for opium also confers toler- corrective lenses, but they do not treat disorders
ance, so that people suffering great pain may of the eye, referring patients with a disorder to a
take, with apparently little effect beyond dull- family doctor or ophthalmologist.
ing the pain, quantities which at another time
would be dangerous. Optic Nerve
See EYE.
Opportunistic
A description usually applied to infection Optic Neuritis
resulting from an organism that does not nor- Inflammation of the optic nerve (see EYE) which
mally cause disease in a healthy individual. It is may result in sudden loss of part of a persons
also used to describe widespread infection by an vision. It is usually accompanied by pain and
organism that usually causes local infection. tenderness on touch. The cause is uncertain,
The bodys defence mechanism can usually although in some cases it may be a prcursor of
combat these organisms, but if it is impaired MULTIPLE SCLEROSIS (MS): CORTICOSTEROIDS
as happens in AIDS/HIV or other immune may help by improving the loss of visual acuity,
deficiencies opportunistic infection, such as but seems not to check the long-term inflam-
PNEUMONIA, may develop. Some viral and fun- matory activity.
gal infections behave in this way. Antimicrobial
treatment is often effective, even though the Oral
weakness in the bodys defence mechanism An adjective referring to the mouth, or to sub-
cannot be rectified. stances taken by mouth.
 518 Oral Contraceptive

Oral Contraceptive Orf

A contraceptive taken by mouth (see CONTRA- A virus infection of sheep and goats commonly
CEPTION). It comprises one or more synthetic transmitted to farm workers. Red papules on
female hormones, usually an oestrogen (see the hands or wrists become vesicular or pustular
OESTROGENS), which blocks normal OVULA- and resolve spontaneously in a few weeks.
TION, and a progestogen which influences the
PITUITARY GLAND and thus blocks normal con- Organ
trol of the womans menstrual cycle (see MEN- A collection of different tissues that form a dis-
STRUATION). Progestogens also make the uterus tinct structure in the body with a particular
less congenial for the fertilisation of an ovum by function or functions. The LIVER, for example,
the sperm. comprises a collection of different metabolic
cells bound together with connective tissue and
Oral Rehydration Therapy (ORT) liberally supplied with blood vessels; it performs
This is the essential initial treatment for DIAR- vital functions in the breakdown of substances
RHOEA, and is particularly valuable for absorbed from the gastrointestinal tract. Other
dehydrated children in developing countries ill examples of organs are the KIDNEYS, BRAIN and
with diseases such as CHOLERA. A litre of water HEART. (See also TRANSPLANTATION.)
containing one teaspoonful of salt and eight of
sugar, taken by mouth, is readily absorbed. It Organic Disease
replaces salts and water lost because of the diar- A term used in contradistinction to the word
rhoea and usually no other treatment is functional, to indicate that some structural
required. change is responsible for the faulty action of an
In developed countries ORT is useful in ORGAN or other part of the body.
treating gastroenteritis. There are a number of
proprietary preparations, often dispensed as fla-
Organic Substances
Those which are obtained from animal or vege-
voured sachets, including Dioralyte and
table bodies, or which resemble in chemical
Rehydrate.
composition those derived from this source.
Organic chemistry has come to mean the chem-
Oral Surgery istry of the carbon compounds.
A branch of surgery that treats deformities,
injuries or diseases of the TEETH and JAW, as Organophosphorus
well as other areas of the face and mouth. Sur- Organophosphorus insecticides act by inhibit-
O geons doing this work are usually qualified den- ing the action of cholinesterase (see ACETYL-
tists who have done further training in oral and CHOLINE). For this reason they are also toxic to
maxillofacial surgery. humans and must therefore be handled with
great care. The most widely used are PARA-
Orbit THION and MALATHION. Organophosphorus
See EYE.
has also been used to make nerve gases (see BIO-
LOGICAL WARFARE).
Orchidectomy
Operation for the removal of the testicles (one Treatment After contamination with insecti-
or both see TESTICLE) for example, because cides, decontaminate (remove clothes, wash
of cancer. skin). Those treating should wear gloves, mask,
apron and goggles. For symptoms give 2 mg of
Orchidopexy ATROPINE IV every 30 minutes until full atro-
When testes do not descend into the scrotum, pinisation (dry mouth, pulse >70). Up to three
normally in young children (CRYP- days treatment may be needed. Severe poison-
TORCHIDISM), an operation is performed to ing may require pralidoxine mysalate: available
correct this. This is called surgical orchidopexy. from designated centres, this drug should be
The main reason is probably cosmetic; however, given intravenously within 24 hours of
a testis which has descended is less likely to exposure.
become cancerous than one which has not. It is
less likely that treatment improves future Organ Transplantation
fertility. See TRANSPLANTATION.

Orchitis Orgasm
Inflammation of the testicle. (See TESTICLE, DIS- The climax of sexual intercourse. In men this
EASES OF.) coincides with ejaculation of the semen when
 Ossification 519

the muscles of the pelvis force the seminal fluid ARTHROPLASTY) and the treatment of bone
from the prostate into the urethra and out tumours. (See BONE, DISORDERS OF; JOINTS,
through the urethral orifice. In women, orgasm DISEASES OF.)
is typified by irregular contractions of the mus-
cular walls of the vagina followed by relaxation. Orthopnoea
The sensation is more diffuse in women than in A form of difficulty in breathing so severe that
men and tends to last longer with successive the patient cannot bear to lie down, but must
orgasms sometimes occurring. sit or stand up. As a rule, it occurs only in ser-
ious affections of the heart or lungs.
Oriental Sore
This term is a synonym for cutaneous LEISH- Orthoptic Treatment
MANIASIS; others include: Cochin, Delhi, Kan- The examination and treatment by exercises of
dahar, Lahore, Madagascar, Natal, Old World squints and their sequelae (see EYE, DISORDERS
tropical, tropical sore, etc. As with many of the OF).
local names for this infection, it is now rarely
used. Osgood-Schlatters Disease
The form of OSTEOCHONDROSIS involving the
Orlistat tibial tubercle the growing point of the TIBIA.
An inhibitor of the pancreatic enzyme LIPASE, It occurs around PUBERTY, mainly in boys, and
which breaks down fats in food to their con- first manifests itself by a painful swelling over
stituent parts. By inhibiting lipase, the drug the tibial tubercle at the upper end of the tibia.
reduces absorption of dietary fat from the The pain is worst during and after exercise. A
INTESTINE. It is used as an ADJUVANT to a mod- limp with increasing limitation of movement of
est low-calorie diet in people with a BODY MASS the knee-joint develops. The disease usually
2
INDEX of 30 kg/m or more. The drug should clears up without treatment. If pain is trouble-
be prescribed only if diet alone has, over a some, physiotherapy or immobilisation of the
period of four consecutive weeks, resulted in a knee-joint in a plaster cast for up to eight weeks
person losing 2.5 kg or more. Orlistat may may be necessary.
cause oily liquid faeces, urgency to defecate,
excessive wind and, sometimes, headaches, Osmosis
tiredness and anxiety. (See OBESITY.) The passage of fluids through a semipermeable
membrane which separates them, so as to
Ornithosis become mixed with one another. Osmotic pres- O
Ornithosis is an infection of birds with the sure is a term applied to the strength of the
micro-organism known as Chlamydia psittaci, tendency which a fluid shows to do this, and
which is transmissible to humans. depends largely upon the amount of solid
which it holds in solution.
Oropharynx Ossicle
The part of the PHARYNX that lies between the A small bone. The term is usually applied to the
soft PALATE and the HYOID bone. three small bones of the middle EAR malleus,
incus, and stapes that conduct sound from the
Orphenadrine eardrum to the inner ear.
A drug used in the treatment of PARKINSONISM.
Ossification
Orthodontics The formation of BONE. In early life, centres
Orthodontics is the branch of dentistry con- appear in the bones previously represented by
cerned with the prevention and treatment of cartilage or fibrous tissue; and these cells, called
dental irregularities and malocclusion. osteoblasts, initiate the formation of true bone,
which includes the deposition of calcium salts.
Orthopaedics When a fracture occurs, the bone mends by
Originally the general measures, both surgical ossification of the clot which forms between the
and mechanical, for the correction or preven- fragments (see under BONE, DISORDERS OF). In
tion of deformities in children. Now, that old age, an unnatural process of ossification
branch of medical science dealing with skeletal often takes place in parts which should remain
deformity (congenital or acquired), fractures cartilaginous for example, in the cartilages of
and infections of bones, replacement of arth- the larynx and of the ribs, making these parts
ritic joints (hips, knees and fingers see unusually brittle.
 520 Osteitis

Osteitis The primary problem is seen as a change in

Osteitis means inflammation in the substance structure of cartilage and BONE, rather than
of a BONE. Traumatic osteitis is a condition par- an inflammatory SYNOVITIS. Osteoarthritis
ticularly common in footballers, in which the usually implies a loss of the central load-bearing
victim complains of pain in the groin following area of articular hyaline cartilage, with out-
exercise, particularly if this has involved much growth of cartilage at the articular margin and
hip rotation. Examination reveals difficulty in subsequent ossification to form bony out-
spreading the legs and marked tenderness over growths known as OSTEOPHYTES. Osteophytes
the symphysis pubis. It responds well to rest form with increasing age, whether or not there
and the administration of non-steroidal anti- is significant cartilage loss, and in the elderly
inflammatory drugs (NSAIDS) such as ibu- may lead to local frictional symptoms, and in
profen or indomethacin. the spine, to nerve compression.
The condition has a wide range of causes, of
Osteitis Deformans which some, like dysplasia and trauma, are
See PAGETS DISEASE OF BONE. known and others have yet to be identified. The
main clinical problems occur in the hip and
Osteitis Fibrosa Cystica knee. The cartilage loss in the hip usually
A pathological rather than a clinical entity. The occurs in the sixth or seventh decade. It may
term refers to the replacement of BONE by a affect both hips in fairly rapid succession, or
highly cellular and vascular connective tissue. It only one hip; such patients often have no prob-
is the result of osteoclastic and osteoblastic lems in other joints. Cartilage loss in the knee
activity and is due to excessive PARATHYROID occurs from the fifth decade onwards and is
activity. It is thus seen in a proportion of often associated with cartilage loss in small
patients with primary hyperparathyroidism and joints in the hand and elsewhere. Cartilage loss
in patients with uraemic osteodystrophy; that in the distal interphalangeal joints of the hand
is, the secondary hyperparathyroidism that is associated with the formation of bony swell-
occurs in patients with chronic renal disease. ings known as Heberdens nodes.

Osteoarthritis Treatment Management is largely directed at

Despite major efforts, it has proved impossible maintaining activity, with physical and social
to produce a single clear definition of osteo- support as necessary. ANALGESICS may be of
arthritis and this probably reflects the muddled some value, particularly in the management of
O nature of a concept which will need replacing. night pain. NON-STEROIDAL ANTI-
Unfortunately, there is confusion because the INFLAMMATORY DRUGS (NSAIDS) may help
term is also used to cover joint pain that appears patients with early-morning stiffness and may
to have a mechanical basis in the absence of also reduce pain on movement and night pain.
clinical or radiographic evidence of CARTILAGE Their benefit, however, tends to be less marked
loss. than in RHEUMATOID ARTHRITIS and their

Right lateral view of vertical section through knee-joint: normal joint (left); degenerated joint cartilage
and eroded bone surfaces of arthritic knee (right).
 Otic Barotrauma 521

long-term usage has considerable toxicity prob- due to inadequate mineralisation of osteoid tis-
lems. Advanced cartilage loss is best treated by sue caused by a deficiency of vitamin D. This
joint replacement. Hip- and knee-joint deficiency may arise because of inadequate
replacements with a wide variety of artificial intake, or it may be due to impaired absorption
joints are now common surgical procedures such as occurs in intestinal malabsorption. It
which greatly improve the mobility of affected may also be due to renal disease, as the kidney is
individuals. (See ARTHROPLASTY.) responsible for the hydroxylation of chole-
People with arthritis and their relatives can calciferol, which has virtually no metabolic
obtain help and advice from Arthritis Care. action, to dihydroxy-cholecalciferol the
metabolically active form of the vitamin. (See
Osteoblast APPENDIX 5: VITAMINS.)
A cell responsible for the production of BONE
(see OSSIFICATION). Osteomyelitis
Inflammation of the BONE as a result of infec-
Osteochondritis tion (see BONE, DISEASES OF).
Inflammation of both BONE and CARTILAGE. It
is a not uncommon cause of BACKACHE in Osteopathy
young people, particularly gymnasts. A system of treatment by manipulating bones
(see BONE) and other parts with the idea of
Osteochondrosis thereby restoring functions in the bodily mech-
This includes a group of diseases involving anism that have become deranged. Properly
degeneration of the centre of OSSIFICATION (see qualified osteopaths are included on the
also BONE) in the growing bones of children and General Council and Register of Osteopaths.
adolescents. They include Kohlers disease,
OSGOOD-SCHLATTERS DISEASE, and PERTHES Osteophytes
DISEASE. Bony spurs or projections. They occur most
commonly at the margins of areas of bone
Osteoclast affected by OSTEOARTHRITIS.
A cell that resorbs calcified BONE.
Osteoporosis
See under BONE, DISORDERS OF.
Osteocyte
A BONE cell formed from an OSTEOBLAST or
Osteosarcoma
bone-forming cell that has stopped its activity. Osteosarcoma, or osteogenic sarcoma, is the O
The cell is embedded in the matrix of the bone. most common, and most malignant, tumour of
bone (see BONE, DISORDERS OF). It occurs pre-
Osteogenesis dominantly in older children and young adults;
See OSSIFICATION.
the most common site is at the ends of the long
bones of the body i.e. the femur, tibia and
Osteogenesis Imperfecta humerus. Treatment is by CHEMOTHERAPY and
A hereditary disease due to an inherited surgical reconstruction or amputation of the
abnormality of COLLAGEN. It is characterised by affected limb. The five-year survival rate is over
extreme fragility of the skeleton, resulting in 70 per cent.
fractures and deformities. It may be accom-
panied by blue sclera (the outermost, normally Osteotomy
white coat of the eyeball), transparent teeth, The operation of cutting of a BONE.
hypermobility (excessive range of movement) of
the joints, deafness, and dwarfism (shortness of Os Trigonum
stature). The exact cause is not known, A small accessory BONE behind the ankle-joint
although there is some evidence that it may be which is present in about 7 per cent of the
associated with collagen formation. Parents of population. It may be damaged by energetic
affected children can obtain help and advice springing from the toes in ballet, jumping or
from the Brittle Bone Society. fast bowling.
Osteogenic Sarcoma OTC
See OSTEOSARCOMA. See OVER-THE-COUNTER (OTC).

Osteomalacia Otic Barotrauma

Osteomalacia is the adult form of RICKETS. It is Also called aerotitis, this is blockage of the
 522 Otitis

Eustachian tubes between the middle EAR and develop. Only a small proportion of these reach
the PHARYNX as a result of rapidly changing maturity, when the ovum is described as a
external air pressure, such as occurs during des- Graafian follicle. OVULATION occurs and, if the
cent of an aircraft. VALSALVAS MANOEUVRE ovum is fertilised, a pregnancy may develop.
pinching the nose with finger and thumb and (See also ENDOCRINE GLANDS; OESTRADIOL;
attempting to blow hard through the nose OESTROGENS; PROGESTERONE.)
will usually relieve the blockage. People prone
to this phenomenon may find nasal decongest- Ovaries, Diseases of
ants helpful. Ophoritis (infection of the ovaries) rarely
occurs alone, except in viral infections such as
Otitis mumps. Usually it is associated with infection
Inflammation of the EAR. (See EAR, DISEASES of the FALLOPIAN TUBES (SALPINGITIS). It may
OF.) occur as a complication of a miscarriage, a
therapeutic abortion, or the birth of a baby.
Otolaryngology Cases not associated with pregnancy typically
The study, diagnosis and treatment of disorders result from sexual activity: the most common
of the ears, throat and larynx. organisms involved are Chlamydia, E. coli, and
Neisseria gonorrhoea. Cervical swabs should be
Otology sent for culture and analgesics given, together
Otology is that branch of medical science which with the appropriate antibiotics.
is concerned with disorders and diseases of the Failure of OVULATION is the cause of
organ of hearing one practising this branch INFERTILITY in around a third of couples seek-
being called an otologist. ing help with conception. It may also lead to
menstrual problems (see MENSTRUATION), such
Otorhinolaryngology as an irregular menstrual cycle or MENOR-
The study of diseases of the ear, nose, and RHAGIA. An uncommon cause of failure of ovu-
throat colloquially referred to as ear, nose and lation is POLYCYSTIC OVARY SYNDROME, often
throat (ENT) specialty. The relevant specialist associated with acne, hirsutism, and obesity.
is called an otorhinolaryngologist (US) or ENT Treatment depends on the symptoms. Early
surgeon (UK). ovarian failure is the cause of premature MENO-
PAUSE. Treatment consists of hormone replace-
Otorrhoea ment therapy using a combination of oestrogen
O Discharge from the EAR. (See EAR, DISEASES OF.) and progestogen.
Ovarian cysts (for example, follicular cysts)
Otosclerosis result from ovulation. They may be symptom-
See under EAR, DISEASES OF. less but sometimes cause abdominal pain, pain
during intercourse or disturbances in menstru-
Otoscope ation. Twisting or rupture can cause severe
See AURISCOPE. pain, pyrexia (fever) and nausea, and explora-
tive surgery endoscopic laparotomy may be
Outpatient needed to establish a diagnosis (symptoms of
A patient attending a hospital clinic who is not ECTOPIC PREGNANCY are similar). The ovary
admitted to a bed. Most patients attend an out- may have to be removed. Simple cysts often
patients department after referral for a special- disappear of their own accord but a large cyst
ist opinion by their general practitioner. An can cause pressure on surrounding structures
increasing number of investigations and treat- and therefore should be surgically removed.
ments, including surgery, are being done on an In young women the most common benign
outpatient basis. tumour is a dermoid cyst, while in older
women, fibroma (see under UTERUS, DISEASES
Ovaries OF) is more common. All benign tumours
The main female reproductive organs which should be removed surgically in order to be sure
produce the ova (egg cells see OVUM) and they are not malignant.
steroid HORMONES in a regular cycle (see Malignant tumours may be primary (arising
MENSTRUATION) in response to hormones (see in the ovary) or secondary (metastases from a
GONADOTROPHINS) from the anterior PITUIT- cancer developing in another organ). Treatment
ARY GLAND. Situated one on each side of the depends upon the site and type of the primary
uterus in the lower abdomen, each ovary con- tumour.
tains numerous follicles within which the ova Around 5,000 women a year are diagnosed as
 Oximeter 523

having ovarian cancer in England and Wales. many plants including rhubarb and sorrel.
Unfortunately it is not readily detected in its Oxalic acid, when swallowed, produces burning
early stages; around 85 per cent of women do of the mouth and throat, vomiting of blood,
not see a doctor until after the tumour has breathlessness and circulatory collapse. Calcium
spread. Early tumours present with symptoms salts, lime water or milk should be given by
similar to benign tumours, while late ones pres- mouth. An injection of calcium gluconate is an
ent with abdominal distension, pain and vague antidote.
gastrointestinal symptoms. The disease is most
common in menopausal women. Earlier diag- Oxaliplatin
nosis and treatment can be achieved by ULTRA- A platinum-based anticancer drug given intra-
SOUND screening. Treatment is surgical, aimed venously for the treatment of colorectal cancer
at totally removing the tumour mass. Nowadays with metastases. It is usually combined with
RADIOTHERAPY is only used for palliation. FLUOROURACIL and folinic acid. Side-effects
CHEMOTHERAPY is often given to patients with include toxic damage to the nervous system.
ovarian metastases, or who have residual disease
after surgery. The most active cytotoxic agent Oxalosis
is the taxane, PACLITAXEL especially when it is An inherited defect in the bodys METABOLISM
combined with cisplatin. in which oxalates a product of metabolism
are deposited in the KIDNEYS and other tissues,
Ovariotomy ultimately causing failure of the kidneys.
Also called ophorectomy. The operation of
removal of an ovary (see OVARIES) or an ovarian Oxaluria
tumour (see under OVARIES, DISEASES OF). The presence in the URINE of OXALIC ACID or
oxalates, in particular calcium oxalate (see
Overbite OXALOSIS).
A dental term describing the condition where a
persons upper INCISOR teeth vertically overlap Oxazepam
the lower incisors. If serious, the person may A benzodiazpine anxiolytic drug (see BENZO-
need orthodontic correction and this is usually DIAZEPINES; ANXIOLYTICS). Like all benzo-
done in childhood after the permanent teeth diazepines, oxazepam should be prescribed with
have developed. caution at the lowest possible dosage for the
shortest possible time, as patients can become
Over-The-Counter (OTC) dependent on it (see DEPENDENCE). The indica- O
A description applied in the UK to MEDICINES tion for use is short-term relief of severe anxiety,
and drugs that can be obtained from a pharma- including panic attacks. Oxazepam has an
cist without a doctors or dentists prescription. advantage over many diazepams in being
Some medications may be bought from retail shorter acting, and it can be used for patients
outlets other than pharmacists. with impairment of LIVER function. The drug is
inappropriate for treatment of DEPRESSION,
Ovulation obsessional states or PSYCHOSIS (see MENTAL
The development and release of an OVUM (egg) ILLNESS).
from the ovary (see OVARIES) into the FALLOPIAN
TUBES. Ovulation is initiated by the secretion of Oxidant
luteinising hormone by the anterior PITUITARY A molecule that causes biological oxidation in
GLAND and occurs half way through the men- which OXYGEN is added to or electrons removed
strual cycle. If the ovum is not fertilised, it is from a substance. Oxygen-free radicals are
lost during MENSTRUATION. highly toxic atoms and chemical groups pro-
duced by intracellular activity in various disease
Ovum processes and by poisons, radiation, smoking
The single cell derived from the female, out of and other pollutants. Anti-oxidants such as
which a future individual arises, after its union beta-carotene can neutralise these radicals.
with the SPERMATOZOON derived from the
male. It is about 35 micrometres in diameter. Oximeter
(See FETUS; OVARIES.) An non-invasive device which can be attached
to a patients skin by an adhesive and records
Oxalic Acid the degree of OXYGEN saturation in their blood,
This is an irritant poison that is used domestic- displaying the level on a screen. It also records
ally for cleaning purposes. It is also found in pulse rate. Oximeters have become essential to
 524 Oximetry

safe managament of severe respiratory illness as required by the tissues is greater than can be
they provide one measure of the lungs ability to supplied by aerobic cellular metabolism and the
exchange oxygen and carbon dioxide. additional energy is supplied by a biochemical
reaction called anaerobic metabolism. There is a
Oximetry build-up of lactate a product of LACTIC ACID
The measurement by an OXIMETER of the pro- from anaerobic metabolism which is ultim-
portion of oxygenated HAEMOGLOBIN in the ately oxidised after conversion to citrate and
blood. metabolism via the citric acid cycle. The
increased amount of oxygen above resting con-
Oxprenolol centrations which needs to be consumed to per-
See ADRENERGIC RECEPTORS. form this metabolism is known as the oxygen
debt or deficit.
Oxycephaly
A deformity of the skull in which the forehead Oxygen Tent
is high and the top of the head pointed. There A sheet of plastic put over a hospital bed with
is also poor vision and the eyes bulge. OXYGEN fed into it so that a patient can receive
oxygen. Such treatment may be for a heart or
Oxygen lung condition in which the normal atmos-
A colourless and odourless gas of molecular pheric concentration of oxygen is insufficient to
weight 32. It constitutes just less than 21 per enable the person to oxygenate the blood flow-
cent of the earths atmosphere. As a medical ing through the lungs to a normal level, so extra
gas, it is supplied in the UK compressed at high oxygen is provided in the patients immediate
pressure (13,600 kilopascals (KPa)) in cylinders surroundings.
which are black with white shoulders. In hos-
pitals, oxygen is often stored as a liquid in insu- Oxygen Toxicity
lated tanks and controlled evaporation allows OXYGEN toxicity in human lungs causes an
the gas to be supplied via a pipeline at a much acute OEDEMA followed by fibrosis and
lower pressure. PULMONARY HYPERTENSION. In the neonate,
Oxygen is essential for life. It is absorbed via retrolental fibroplasia occurs and central-
the lungs (see RESPIRATION) and is transported nervous-system damage may result in the infant
by HAEMOGLOBIN within the ERYTHROCYTES having fits. Several factors are involved in tox-
to the tissues. Within the individual cell it is icity and there is no absolute relationship to
O involved in the production of adenosine tri- time or concentration, although inspired con-
phosphate (ATP), a compound that stores centrations of under 50 per cent are probably
chemical energy for muscle cells, by the oxida- safe for long periods.
tive metabolism of fats and carbohydrates.
HYPOXIA causes anaerobic metabolism with a Oxyhaemoglobin
resulting build-up in LACTIC ACID, the result of The compound formed when the pigment
muscle cell activity. If severe enough, the lack of HAEMOGLOBIN in the ERYTHROCYTES (red
ATP causes a breakdown in cellular function blood cells) combines with OXYGEN (a revers-
and the death of the individual. ible reaction). The oxygen is carried in this way
When hypoxia occurs, it may be corrected by from the lungs to the bodys tissues where it is
giving supplemental oxygen. This is usually released to take part in metabolic activities.
given via a face mask or nasal prongs or, in
severe cases, during ARTIFICIAL VENTILATION Oxytetracycline
OF THE LUNGS. Some indications for oxygen Oxytetracycline is an antibiotic derived from a
therapy are high altitude, ventilatory failure, soil organism, Streptomyces rimosus. Its range of
heart failure, ANAEMIA, PULMONARY HYPER- antibacterial activity is comparable to that of
TENSION, CARBON MONOXIDE (CO) poisoning, tetracycline (see TETRACYCLINES).
anaesthesia and post-operative recovery. In
some conditions e.g. severe infections with Oxytocin
anaerobic bacteria and CO poisoning hyper- Oxytocin is the extract isolated from the pituit-
baric oxygen therapy has been used. ary posterior lobe which stimulates the uterine
muscle to contract. Oxytocin produced by the
Oxygen Deficit PITUITARY GLAND stimulates the flow of milk in
In a resting individual the potential OXYGEN breast-feeding mothers. It can also be syn-
supply to the tissues is greater than its con- thesised. The synthetic form is used to induce
sumption. During heavy exercise, the energy or assist labour in pregnancy and childbirth and
 Ozone 525

also to encourage the expelling of the PLACENTA Ozone

(afterbirth). Sometimes it is given to a woman A specially active and poisonous form of OXY-
who has had an incomplete miscarriage (see GEN in which three volumes of the gas are con-
ABORTION). There have been criticisms that densed into the space ordinarily occupied by
oxytocin is used too often to induce labour for two. It has a characteristic smell and is a strong
social reasons or for the convenience of obstet- oxidising agent. Formed when an electrical
ric departments. (See also PITUITARY BODY.) charge is passed through oxygen or air, it is
found at high altitudes in the atmosphere where
Oxyuriasis it screens out much of the suns ultraviolet radi-
Another name for the threadworm (see ation. The ozone layer, as it is called, is being
ENTEROBIASIS). damaged by pollutant gases from earth. Unless
this damage is reversed, lethal quantities of
Ozaena ultraviolet radiation could penetrate to the
A chronic disease of the NOSE of an inflamma- earths surface, further warming the worlds
tory nature, combined with atrophy of the climates, with long-term damage to the
mucous membrane and the formation of environment.
extremely foul-smelling crusts in the interior of
the nose. (See also NOSE, DISORDERS OF.)

O
 as first-line treatment is limited to clinical

P trials.
Side-effects of paclitaxel include hyper-
sensitivity, MYELOSUPPRESSION,
ARRHYTHMIA and peripheral NEUROPATHY.
cardiac

Only a minority of patients respond to the

drug, but when it works the results are often
Pacemaker long-lasting.
A cardiac or artificial pacemaker is a device that
helps a faulty HEART to maintain normal PACS
rhythm. It consists of a battery that stimulates See PICTURE ARCHIVING AND COMMUNICA-
the heart by an electric current passed through TIONS SYSTEM (PACS).
an insulated wire which is attached either to the
surface of the ventricle (epicardial pacemaker) Paederasty
or to the heart lining (endocardial pacemaker). A homosexual act between an adult man and a
In a normal heart, the regular electrical boy or young man (see HOMOSEXUALITY).
impulses are initiated by a special area of tissue
(sinoatrial node). A cardiac pacemaker is used Paediatrician
when a persons sinoatrial node is malfunction- A medical specialist skilled in the care of child-
ing or when there is interference with the pas- rens health and diseases.
sage of normal impulses. Some devices send out
signals at a fixed rate; others monitor the rate Paediatrics
and, when it falters in any way, stimulate regu- Paediatrics means the branch of medicine
lar contractions. Implantation is carried out dealing with diseases of children (see also
under a local anaesthetic, and the lithium bat- NEONATOLOGY).
teries can last for several years. People with
pacemakers should avoid any source of power- Paedophilia
ful electromagnetic radiation radio or radar A perverse sexual attraction to children of either
transmitters or airport security screens. (See also sex. Paedophiles are nearly always male and may
CARDIAC PACEMAKER.) have heterosexual, homosexual or bisexual
orientation.
Pacinian Corpuscles In England and Wales, the age of consent for
Pacinian corpuscles, or lamellated corpuscles, heterosexual and homosexual sex is 16 years; in
are minute bulbs at the ends of the nerves scat- Northern Ireland, 17 years; and in Scotland the
tered through the SKIN and subcutaneous tis- age of consent for heterosexual sex is 12 for a
sue, and forming one of the end-organs for girl and 14 for a boy. However, girls are pro-
sensation. tected by Section 5 of the Criminal Law (Con-
solidation) Act 1995 which makes it an offence
Packed Cell Volume to have sexual intercourse with a girl aged under
That fraction of the bloods total volume made 16. For girls under 13, the maximum sentence
up of red cells. The packed cell volume is found is life-imprisonment, and between 13 and 16,
by centrifuging blood in a tube and measuring two years imprisonment. Homosexual consent
the depth of the column of red cells as a fraction in Scotland is 16.
of the whole column of blood. (See also Paedophiles suffer from personality problems
HAEMATOCRIT.) rather than overt psychoses (see PSYCHOSIS) and
the origins of their behaviour may lie in their
Paclitaxel own early sexual experiences. Their behaviour
A CYTOTOXIC drug of the taxane group (see often has features of an addiction.
TAXANES). Given by intravenous transfusion, it It is of note that most underaged sex is
is used under specialist supervision for the between family members such as stepfather and
treatment of ovarian cancer (usually following daughter rather than with a stranger or preda-
surgery see OVARIES, DISEASES OF) with or tory paedophile.
without CISPLATIN. NATIONAL INSTITUTE FOR (See CHILD ABUSE.)
CLINICAL EXCELLENCE (NICE) guidance in
2001 also recommended that the drug could Pagets Disease of Bone
be used to treat advanced breast cancer (see Also called osteitis deformans, this is a chronic
BREASTS, DISEASES OF) where initial cytotoxic disease in which the bones (see BONE) espe-
therapy had failed or could not be used. Its use cially those of the skull, limbs, and spine
 Pain 527

gradually become thick and also soft, causing incoming sensory modalities, as well as des-
them to bend. It is said to be the most common cending input from the brain (Melzack and
form of bone disease in the world, and it is Walls gate-control theory). This involves
estimated that some 600,000 people in England morphine-like molecules (the ENDORPHINS and
may suffer from it. It seldom occurs under the ENKEPHALINS) amongst many other pain-
age of 40. Pain is its most unpleasant manifest- transmitting and pain-modulating substances.
ation. The cause is not known, and there is no The modified input then passes up the spinal
known cure, but satisfactory results are being cord through the thalamus to the cerebral cor-
obtained from the use of CALCITONIN and a tex. Thus the amount of pain felt may be
group of drugs known as BISPHOSPHONATES altered by the emotional state of the individual
(e.g. etidronate). Those with the disease can and by other incoming sensations. Once pain is
obtain help and advice from the National perceived, then action is taken; this involves
Association for the Relief of Pagets Disease. withdrawal of the area being damaged, vocalisa-
tion, AUTONOMIC NERVOUS SYSTEM response
Pain and examination of the painful area. Analysis of
Pain is an unpleasant sensory and emotional the event using memory will occur and
experience associated with actual or potential appropriate action be taken to reduce pain and
tissue damage, or described in terms of such treat the damage.
damage (International Association for the
Study of Pain, 1979). Pain is perceived in the Chronic pain may be defined in several
cerebral cortex (see BRAIN) and is always sub- ways: for example, pain resistant to one
jective. Sometimes sensations that would months treatment, or pain persisting one
usually be benign can be perceived as painful month beyond the usual course of an acute ill-
for example, allodynia (extreme tenderness of ness or injury. Some doctors may also arbitrarily
the skin) or dysaesthesia (unpleasant skin sen- choose the figure of six months. Chronic pain
sations resulting from partial damage to sens- differs from acute pain: the physiological
ory nerve fibres, as in herpes zoster, or response is different and pain may either be
shingles). caused by stimuli which do not usually cause
the perception of pain, or may arise within
Acute pain is caused by internal or external nerves or the central nervous system with no
injury or disease. It warns the individual that apparent external stimulation. It seldom has a
harm or damage is occurring and stimulates physiological protective function in the way
them to take avoiding or protective action. acute pain has. Also, chronic pain may be self-
With effective treatment of disease or injury perpetuating: if individuals gain a psychological
and/or the natural healing process, the pain advantage from having pain, they may con- P
resolves although some acute pain syndromes tinue to do so (e.g. gaining attention from fam-
may develop into chronic pain (see below). ily or health professionals, etc.). The nervous
Stimuli which are sufficiently intense potentially system itself alters when pain is long-standing
to damage tissue will cause the stimulation of in such a way that it becomes more sensitive to
specific receptors known as NOCICEPTORS. painful inputs and tends to perpetuate the
Damage to tissues releases substances which pain.
stimulate the nociceptors. On the surface of the
body there is a high density of nociceptors, and Treatment The treatment of pain depends
each area of the body is supplied by nerves from upon its nature and cause. Acute pain is gener-
a particular spinal segment or level: this allows ally treated by curing the underlying complaint
the brain to localise the source of the pain and prescribing ANALGESICS or using local
accurately. Pain from internal structures and anaesthetic techniques (see ANAESTHESIA
organs is more difficult to localise and is often Local anaesthetics). Many hospitals now have
felt in some more superficial structure. For acute pain teams for the management of post-
example, irritation of the DIAPHRAGM is often operative and other types of acute pain; chronic
felt as pain in the shoulder, as the nerves from pain is often treated in pain clinics. Those
both structures enter the SPINAL CORD at the involved may include doctors (in Britain, usu-
same level (often the structures have developed ally anaesthetists), nurses, psychologists and
from the same parts of the embryo). This is psychiatrists, physiotherapists and comple-
known as referred pain. mentary therapists. Patients are usually referred
The impulses from nociceptors travel along from other hospital specialists (although some
nerves to the spinal cord. Within this there is may be referred by GPs). They will usually have
modulation of the pain messages by other been given a diagnosis and exhausted the
 528 Palate

medical and surgical treatment of their under- Palate

lying condition. The partition between the cavity of the mouth,
All the usual analgesics may be employed, below, and that of the nose, above. It consists of
and opioids are often used in the terminal the hard palate towards the front, which is
treatment of cancer pain. composed of a bony plate covered below by the
ANTICONVULSANTS and ANTIDEPRESSANT mucous membrane of the mouth, above by that
DRUGS are also used because they alter the of the nose; and of the soft palate further back,
transmission of pain within the central nervous in which a muscular layer, composed of nine
system and may actually treat the chronic pain small muscles, is similarly covered. The hard
syndrome. palate extends a little further back than the wis-
Many local anaesthetic techniques are used. dom teeth, and is formed by the maxillary and
Myofascial pain pain affecting muscles and palate bones. The soft palate is concave towards
connective tissues is treated by the injection the mouth and convex towards the nose, and it
of local anaesthetic into tender spots, and ends behind in a free border, at the centre of
nerves may be blocked either as a diagnostic which is the prolongation known as the uvula.
procedure or by way of treatment. Epidural When food or air is passing through the mouth,
anaesthetic injections are also used in the same as in the acts of swallowing, coughing, or
way, and all these treatments may be repeated at vomiting, the soft palate is drawn upwards so as
intervals over many months in an attempt to to touch the back wall of the throat and shut off
cure or at least reduce the pain. For intractable the cavity of the nose. Movements of the soft
pain, nerves are sometimes destroyed using palate, by changing the shape of the mouth and
injections of alcohol or PHENOL or by applying nose cavities, are important in the production
CRYOTHERAPY or radiofrequency waves. of speech.
Intractable or terminal pain may be treated by
destroying nerves surgically, and, rarely, the Palate, Malformations of
pain pathways within the spinal cord are The commonest deformity of the PALATE is cleft
severed by cordotomy (though this is generally palate, which is a result of faulty embryonic
only used in terminal care). development in which the two sides of the pal-
ACUPUNCTURE and TRANSCUTANEOUS ate fail to fuse or only fuse in part. If the cleft
ELECTRICAL NERVE STIMULATION (TENS) are extends the full length with bilateral clefts at the
used for a variety of pain syndromes, particu- front of the MAXILLA, it may be accompanied by
larly myofascial or musculoskeletal pain. It is a cleft lip (also called hare-lip) and disruption in
thought that they work by increasing the release the development of the front teeth. About 1 in
of endorphins and enkephalins (see above). It is 500 babies is born with a cleft lip and 1 in 1,000
P possible to implant electrodes within the epi- has a cleft palate. If the parents are affected, the
dural space to stimulate directly the nerves as risk is three times that of the normal population;
they traverse this space before passing into the if one child has a deformity, the risk for a sub-
spinal cord. sequent child is higher. Associated abnormalities
Physiotherapy is often used, particularly in include tongue tie, malpositioning of the MAN-
the treatment of chronic backache, where pain DIBLE and fluid in the middle EAR.
may be reduced by improving posture and Cleft palate and hare-lip should be rectified
strengthening muscles with careful exercises. by operation, because both are a serious draw-
Relaxation techniques and psychotherapy are back to feeding in early life while later, hare-
also used both to treat chronic pain and to help lip is a great disfigurement, and the voice may
patients cope better with their disability. be affected. The lip may be dealt with at any
Some types of chronic pain are caused by time from the neonatal period to a few weeks,
injury to sympathetic nerves or may be relieved depending on the individual surgeons view of
by interrupting conduction in sympathetic when the best result is likely to be achieved.
nerves. This may be done in several ways. The Prior to operation, special techniques may be
nerves may be blocked using local anaesthetic necessary to ensure adequate feeding such as the
or permanently destroyed using alcohol, phenol use of special teats in formula-fed babies. The
or by surgery. closure of a large cleft in the palate is a more
Many of these techniques may be used in the formidable operation and is better performed
management of cancer pain. Opioid drugs are when the face has grown somewhat, perhaps at
often used by a variety of routes and methods, 612 months. The operations performed vary
and management of these patients concentrates greatly in details, but all consist in paring the
on the control of symptoms and on providing a edges of the gap and drawing the soft parts
good quality of life. together across it.
 Palpitation 529

Further operations may be required over the accelerated death may suggest that he or she is
years to improve the appearance of the nose and depressed a treatable condition or that the
lip, to make sure that teeth are even, and to palliative care is inadequate and needs review-
improve speech. ing and, if possible, improving.
Parents of such children can obtain help and
advice from the Cleft Lip and Palate Associ- Pallidotomy
ation (CLAPA). Also known as pallidectomy, this is a neuro-
surgical procedure in which the activities of the
Palilalia globus pallidus area of the BRAIN are destroyed
Also called paliphrasia, this means the involun- or modified. The operation is sometimes used
tary repetition of words or sentences. It is a to relieve the symptoms of PARKINSONISM and
symptom of GILLES DE LA TOURETTES other neurological conditions in which
SYNDROME. involuntary movements are a significant and
disabling symptom.
Palindromic
An adjective describing symptoms or diseases Pallor
that recur. For example, palindromic rheumatoid Unusual paleness of the SKIN caused by a
arthritis is a condition in which symptoms wax reduced flow of blood or a deficiency in normal
and wane with periods of complete remission. pigments. Pallor may be a sign of fright,
SHOCK, ANAEMIA, or other diseases.
Palliative
A term applied to treatment that eases the Palpation
symptoms of a disorder rather than curing the Examination of the surface of the body and the
condition. (See also HOSPICE; PALLIATIVE CARE.) size, shape, and movements of the internal
organs, by laying the flat of the hand upon the
Palliative Care skin.
This is defined as comprehensive care of
patients and families facing terminal illness. Palpebral
The care focuses primarily on comfort and sup- Relating to the eyelid (see EYE).
port. Such care includes:
careful control of symptoms, especially PAIN. Palpitation
psychosocial and spiritual care. Forcible and/or irregular beating of the HEART
a personalised management plan centred on
the patients needs and wishes.
such that the person becomes conscious of its
action.
care that takes into account the familys P
needs and that is carried into the bereave- Causes As a rule, a person is not conscious of
ment period. the beating of the heart except when the ner-
provision of coordinated services in the
home, hospital, day-care centre and other
vous system is unduly excited. A disorder of the
rhythm of the heart (ARRHYTHMIA) may cause
facilities used by the patient. palpitations. Sudden emotions, such as fright,
Palliative care should include: managing or overuse of tobacco, tea, coffee or alcohol may
chronic cancer pain with planned use of com- bring it on. Sometimes it may appear in people
mon ANALGESICS including opioids (see SYR- with organic heart disease.
INGE DRIVERS); planning ahead to preserve as
far as possible the patients autonomy and Symptoms There may simply be a fluttering
choice as death approaches and the ability to of the heart and a feeling of faintness, or the
make decisions may decline; and an under- heart may be felt pounding and the arteries
standing and use of artificial feeding and throbbing, causing great distress. The subject
hydration. Palliative care seeks to improve the may be conscious of the heart missing beats.
satisfaction of both patient and family, to iden-
tify their needs and, if possible, to reduce the Treatment Although these symptoms can be
overall cost because the patient can often be unpleasant, they do not necessarily signify ser-
looked after at home or in a HOSPICE instead of ious disease. Moderate exercise is a good thing.
in hospital. If the person is a smoker, he or she should stop.
A well-publicised question that may arise in Tea, coffee, alcohol or other stimulants should
the context of palliative care is physician- be taken sparingly. If symptoms persist or are
assisted suicide. This subject is referred to in the severe, the individual should see a doctor and
entry on ETHICS. A request by a patient for any underlying disorder should be investigated
 530 Palsy

including by exercise ECG and treated. The which digest proteins; AMYLASE, which converts
BETA-ADRENOCEPTOR-BLOCKING DRUGS are starchy foods into the disaccharide maltose;
the most useful drugs in controlling the palpita- and LIPASE, which breaks up fats. (See also
tions of anxiety and those due to some cardiac DIGESTION.)
arrhythmias. Inadequate production of insulin by the islets
of Langerhans leads to the condition known as
Palsy DIABETES MELLITUS. In addition to insulin,
Another name for PARALYSIS. CEREBRAL PALSY another hormone is produced by the pancreas:
involves total or partial paralysis of a limb or this is glucagon which has the opposite effect to
limbs due to a perinatal or early infancy brain insulin and raises the blood sugar by promoting
lesion. the breakdown of liver glycogen.

Pan- Pancreas, Disorders of

A prefix meaning all or completely.
Diabetes See DIABETES MELLITUS.
Panacea
Panacea is a term applied to a remedy for all Pancreatic cancer The incidence of pan-
diseases, or more usually to a remedy which creatic cancer is rising: around 7,000 cases are
benefits many different diseases. now diagnosed annually in the UK, accounting
for 12 per cent of all malignancies. There is an
Pancarditis established association with heavy cigarette-
Inflammation of the pericardium, myocardium, smoking, and the cancer is twice as common in
and endocardium at the same time (see HEART patients with diabetes mellitus as compared
Structure). with the general population. Cancer of the pan-
creas is hard to diagnose; by the time symptoms
Pancreas occur the tumour may be difficult to treat sur-
A gland situated in the back of the abdomen, at gically with PALLIATIVE bypass surgery the
the level of the first and second lumbar ver- only procedure.
tebrae. It lies behind the lower part of the stom-
ach, an expanded portion called the head of Chronic pancreatitis may be painless; it
the pancreas occupying the bend formed by leads to pancreatic failure causing MALABSORP-
the duodenum or first part of the small intes- TION SYNDROME and diabetes mellitus, and the
tine, whilst a long portion known as the body pancreas becomes calcified with shadowing on
extends to the left, ending in the tail which X-RAYS. The malabsorption is treated by a low-
P rests against the spleen. A duct runs through the fat diet with pancreatic enzyme supplements;
whole gland from left to right, joined by many the diabetes with insulin; and pain is treated
small branches in its course, and, leaving the appropriately. Surgery may be required.
head of the gland, unites with the bile duct
from the liver to open into the side of the small Acute pancreatitis An uncommon disease
intestine about 7510 cm (34 inches) below of the pancreas which may start gradually or
the outlet of the stomach. suddenly, usually accompanied by severe
Scattered through the pancreas are collec- abdominal pain which often radiates through to
tions of cells known as the ISLETS OF LANGER- the back. Biliary tract disease and alcohol
HANS, of which there are around a million in a account for 80 per cent of patients admitted
normal individual. These do not communicate with acute pancreatitis, while other causes
with the duct of the gland, and the internal include drugs (see AZATHIOPRINE and DIURET-
secretion of the pancreas INSULIN is formed ICS) and infections such as MUMPS. Patients are
by these cells and absorbed directly into the acutely ill with TACHYCARDIA, fever and low
blood. blood pressure; many go into SHOCK. The con-
dition may be mistaken for a perforated PEPTIC
Functions The most obvious function of the ULCER, except that in acute pancreatitis the
pancreas is the formation of the pancreatic blood concentration of AMYLASE is raised. The
juice, which is poured into the small intestine main complication is the formation of a PSEU-
after the partially digested food has left the DOCYST. Treatment includes intravenous
stomach. This is the most important of the feeding, ANTICHOLINERGIC drugs and
digestive juices, is alkaline in reaction, and con- ANALGESICS. Regular measurements of blood
tains (in addition to various salts) four enzymes GLUCOSE, CALCIUM, amylase and blood gases
(see ENZYME) TRYPSIN and CHYMOTRYPSIN, are required. Abdominal ULTRASOUND may
 Papillitis 531

identify gall-stones (see under GALL-BLADDER, or PHOBIA. If troublesome or disabling, attacks

DISEASES OF). If the patient deteriorates, he or can be treated symptomatically with short-term
she should be admitted for intensive care as ANXIOLYTICS or on a long-term basis with
haemorrhagic pancreatic necrosis may be devel- BEHAVIOUR THERAPY.
oping. LAPAROTOMY and DEBRIDEMENT may be
called for. Mortality is 510%. Panniculitis
Inflammation of the subcutaneous fat (see FAT
Pancreatin Body fat). It may occur anywhere on the body
Pancreatin preparations (often in the form of a surface.
powder) contain the four powerful enzymes (see
ENZYME), trypsin, chymotrypsin, lipase, and Pannus
amylase, which continue the digestion of foods 1) Blood vessels growing into the cornea (see
started in the stomach (see PANCREAS Func- EYE) beneath its epithelium. Seen in TRACH-
tions; DIGESTION). They are given by mouth OMA and to a lesser extent in patients who are
for the relief of pancreatic deficiency in condi- long-term soft-contact-lens wearers.
tions such as pancreatitis (see PANCREAS, DIS- 2) Inflammatory tissue which replaces CAR-
ORDERS OF) and CYSTIC FIBROSIS. Pancreatin is TILAGE in RHEUMATOID ARTHRITIS.
also used for the preparation of pre-digested, or
so-called peptonised, foods, such as milk and Pantothenic Acid
some starchy foods. This plays an important part in the transfer of
acetyl groups in the bodys METABOLISM and is
Pancreatitis one of the essential constituents of the diet. The
See PANCREAS, DISORDERS OF. daily requirement is probably around 10 milli-
grams. It is widely distributed in food stuffs,
Pancytopenia both animal and vegetable; yeast, liver and egg-
A fall in the number of red ERYTHROCYTES and yolk are particularly rich sources. (See APPENDIX
white LEUCOCYTES, as well as of platelets (see 5: VITAMINS.)
BLOOD Composition). The condition is
found in aplastic ANAEMIA, tumours of the Papanicolaou Test
BONE MARROW, enlarged SPLEEN, and other See CERVICAL SMEAR.
disorders.
Papaveretum
Pandemic The hydrochlorides of ALKALOIDS of OPIUM.
An EPIDEMIC that has spread so widely that very Papaveretum relaxes smooth MUSCLE and has
many people in different countries are affected. the pain-relieving and narcotic effects of MOR- P
Examples include the Black Death the PHINE, but fewer side-effects. It is largely used
epidemic PLAGUE, caused by the bacterium to prepare patients for ANAESTHESIA.
Yersinia pestis, that devastated European popu-
lations in the Middle Ages, killing more than a Papaverine
third of the people; and the INFLUENZA pan- A smooth-muscle (see MUSCLE) relaxant once
demic of 191920 that killed more people than used to treat IMPOTENCE (erectile dysfunction).
did World War I. AIDS/HIV is currently The drug is injected directly into the corpora
pandemic. caverosa (spongy, blood-filled erectile tissue) of
the PENIS. Men with psychogenic or neuro-
Panic Attacks logical impotence may respond to this treat-
Panic attacks, or panic disorders, are recurrent ment. Its use is less common since SILDENAFIL
short episodes of acute distress. Some sufferers (Viagra) was introduced for the treatment of
may be mentally confused and fear impending erectile dysfunction.
death. Initially these attacks tend to occur
unexpectedly but, if recurrent, they often Papilla
become associated with certain places such as a A small projection, such as those with which
confined space (lift) or among crowds. Symp- the corium of the skin is covered, and which
toms include a feeling of breathing difficulties, project into the epidermis and make its union
including overbreathing, PALPITATION, dizzi- with the corium more intimate; or those cover-
ness, sweating, faintness and pains in the chest. ing the tongue and projecting from its surface.
Attacks are usually short (a few minutes) but
not often associated with physical illness, Papillitis
although victims may have an anxiety disorder Inflammation of any PAPILLA, but especially of
 532 Papilloedema

the prominence formed by the end of the optic in a dose of 0.51g by mouth (maximum 4
nerve in the retina (see EYE) also known as doses every 24 hours).
OPTIC NEURITIS.
Paracetamol Poisoning
Papilloedema Paracetamol is one of the safest drugs when
Swelling of the OPTIC DISC of the EYE, specific- taken in the correct dosage, but overdose may
ally due to raised intracranial pressure. It can be occur inadvertently or deliberately. Initially
seen by examining the back of the eye using an there may be no symptoms or there may be
OPHTHALMOSCOPE and is an important sign in nausea, vomiting, abdominal pain and pallor.
managing the care of patients with intracerebral Then, 1624 hours after ingestion, liver dam-
disease such as tumours or MENINGITIS. age becomes evident and by 72120 hours the
patient may have JAUNDICE, COAGULATION
Papilloma abnormalities, hepatic failure (see LIVER, DIS-
Proliferation of epidermis or epithelium (see EASES OF), renal failure (see KIDNEYS, DISEASES
SKIN) to form a tumour. Benign papillomas are OF), ENCEPHALOPATHY and COMA. Treatment
common in the skin and are sometimes viral in involves the administration of antidotes such
origin. Papilloma of the urinary bladder may as METHIONINE (within 8 hours) orally or
cause HAEMATURIA. intravenous ACETYLCYSTEINE.
An overdose of paracetamol is a common
Papova Viruses choice of those attempting to commit suicide.
These include the human papilloma viruses Since the government restricted the number of
(HPV), of which nearly a hundred strains have paracetamol tablets an individual may purchase
been identified. HPV cause verrucae (see over the counter, the incidence of people taking
WARTS) on skin and, less often, on the mucous
the drug in overdose with the intention of
membranes of mouth, larynx, genitalia and the taking their lives has fallen sharply.
cervix. Some strains may predispose to eventual
cancer. Paradoxical Breathing
The reverse of the normal movements of
breathing (see RESPIRATION). The chest wall
Papule moves in instead of out when breathing in
Small (less than 5 mm) solid elevation of the
(inspiration), and out instead of in when
skin or mucous membranes. A larger lesion is
breathing out (expiration). The spaces between
called a nodule.
the ribs are indrawn on inspiration a symp-
tom seen in children with respiratory distress,
Para- say, as a result of ASTHMA or lung infections.
P A prefix meaning near, aside from, or beyond. Patients with CHRONIC OBSTRUCTIVE PUL-
MONARY DISEASE (COPD) often suffer from
Para-Amino Salicylic Acid paradoxical breathing; and trauma to the rib
One of the early antituberculous (see TUBERCU- cage, with fractured sternum and ribs, also
LOSIS) antibiotics. It tended to cause DYSPEPSIA cause the condition. Treatment is of the under-
and has been replaced by newer antituberculous lying cause.
drugs with fewer side-effects. The first-line
drugs for tuberculosis are now rifampicin, Paraesthesia
isoniazid, and ethambutol. A term applied to unusual feelings, apart from
mere increase, or loss, of sensation, experienced
Paracentesis by a patient without any external cause: for
The puncture by hollow needle or TROCAR and example, hot flushes, numbness, tingling, itch-
CANNULA of any body cavity (e.g. abdominal, ing. Various paraesthesiae form a common
pleural, pericardial), for tapping or aspirating symptom in some nervous diseases.
fluid. (See ASPIRATION.)
Paraffin
Paracetamol The general name used to designate a series of
(US, acetaminophen.) A non-opioid analgesic saturated hydrocarbon compounds derived
(see ANALGESICS) similar in efficacy to aspirin, from petroleum. Liquid paraffin is used in the
but without any demonstrable anti- treatment of CONSTIPATION. Externally, the
inflammatory activity. It also has the advantage hard and soft paraffins are used in various con-
over aspirin of causing less gastric irritation. It is sistencies, being very useful as OINTMENTS and
indicated for mild to moderate pain and pyrexia lubricants.
 Paralysis 533

Paraganglion due to some disorder of the NERVOUS SYSTEM.

One of the small ovoid collections of cells Weakness rather than total movement loss is
occurring in the walls of the ganglia of the SYM- sometimes described as paresis. Paralysis may be
PATHETIC NERVOUS SYSTEM adjacent to the temporary or permanent and may be accom-
SPINAL CORD. They are CHROMAFFIN cells and panied by loss of feeling.
sometimes secrete ADRENALINE.
Paralysis due to brain disease The
Paragonimiasis most common form is unilateral palsy, or
A tropical disease found mainly in the Far East. HEMIPLEGIA, generally arising from cerebral
It is caused by infections of the lungs by a para- HAEMORRHAGE, THROMBOSIS or EMBOLISM
sitic fluke called Paragonimus westermani. The affecting the opposite side of the BRAIN. If all
infection is acquired by eating insufficiently four limbs and trunk are affected, the paralysis
cooked shellfish. The affected person has symp- is called quadraplegia; if both legs and part of
toms similar to those of chronic BRONCHITIS; the trunk are affected, it is called paraplegia.
treatment is with the drugs CHLOROQUINE and Paralysis may also be divided into flaccid
bithionol. (floppy limbs) or spastic (rigid).
In hemiplegia the cause may be an abscess,
Paragraphia haemorrhage, thrombosis or TUMOUR in the
Misplacement of words, or of letters in words, brain. CEREBRAL PALSY or ENCEPHALITIS are
or wrong spelling, or use of wrong words in other possible causes. Sometimes damage
writing as a result of a lesion in the speech occurs in the parts of the nervous system
region of the BRAIN. responsible for the fine control of muscle
movements: the cerebellum and basal ganglion
Parainfluenza Viruses are such areas, and lack of DOPAMINE in the
These are included in the paramyxoviruses (see latter causes PARKINSONISM.
MYXOVIRUSES) and divided into four types, all
of which cause infection of the respiratory sys- Damage or injury Damage to or pressure
tem (see RESPIRATION). Infection with type 3 on the SPINAL CORD may paralyse muscles sup-
begins in May, reaches a maximum in July or plied by nerves below the site of damage. A
August and returns to base-line level in Octo- fractured spine or pressure from a tumour may
ber. Types 1 and 2 are predominantly winter have this effect. Disorders affecting the cord
viruses. Children are commonly affected and which can cause paralysis include osteoarthritis
the manifestations include CROUP, fever, and a of the cervical vertebrae (see BONE, DISORDERS
rash. OF), MULTIPLE SCLEROSIS (MS), MYELITIS,
POLIOMYELITIS and MENINGITIS. Vitamin B12 P
Paraldehyde deficiency (see APPENDIX 5: VITAMINS) may also
A clear, colourless liquid with a penetrating cause deterioration in the spinal cord (see also
ethereal (see ETHER) odour, paraldehyde may be SPINE AND SPINAL CORD, DISEASES AND INJUR-
given by mouth, rectally, or occasionally in IES OF).
intramuscular injection. The drugs prime use
is as a hypnotic (see HYPNOTICS) in mentally Neuropathies are a group of disorders,
unstable patients. It is also indicated as an anti- some inherited, that damage the peripheral
convulsant in STATUS EPILEPTICUS (after initial nerves, thus affecting their ability to conduct
intravenous DIAZEPAM) and in TETANUS. Its electrical impulses. This, in turn, causes muscle
unpleasant taste restricts its use, but this has the weakness or paralysis. Among the causes of neu-
advantage that it usually prevents the patient ropathies are cancers, DIABETES MELLITUS, liver
from becoming an addict. disease, and the toxic consequences of some
Caution is needed when treating patients drugs or metals lead being one example.
with bronchopulmonary disease or liver
impairment; and intramuscular injection near Disorders of the muscles themselves
the sciatic nerve should be avoided, as it may for example, muscular dystrophy (see MUSCLES,
cause severe CAUSALGIA. Adverse effects include DISORDERS OF Myopathy) can disturb their
rashes; pain and sterile ABSCESS after intra- normal working and so cause partial or com-
muscular injection; rectal irritation after plete paralysis of the part(s) affected.
ENEMA.
Treatment The aim of treatment should be
Paralysis to remedy the underlying cause for example,
Paralysis, or PALSY, is loss of muscular power surgical removal of a displaced intervertebral
 534 Paralysis

Brain and spinal cord, showing motor paths and positions of injuries causing various forms of paralysis.
 Paraplegia 535

disc or treating diabetes mellitus. Sometimes occasionally, infection may spread to produce a
the cause cannot be rectified but, whether treat- cerebral abscess or cerebral venous sinus throm-
able or not, physiotherapy is essential to prevent bosis (see BRAIN, DISEASES OF).
joints from seizing up and to try to maintain
some tone in muscles that may be only partly Paranoia
affected. With temporary paralysis, such as can A condition whose main characteristic is the
occur after a STROKE, physiotherapy can retrain delusion (see DELUSIONS) that other people are
the sufferers to use their muscles and joints to (in an unclear way) connected to the affected
ensure mobility during and after recovery. individual. A sufferer from paranoia constructs
Patients with permanent hemiplegia, paraplegia a complex of beliefs based on his or her inter-
or quadraplegia need highly skilled nursing pretation of chance remarks or events. Persecu-
care, rehabilitative support and resources, and tion, love, jealousy and self-grandeur are
expert help to allow them, if possible, to live at among the emotions evoked. Acute paranoia
home. a history of less than six months may be the
result of drastic changes in a persons
Paralysis agitans environment, such as war, imprisonment, fam-
See PARKINSONISM. ine or even leaving home for the first time.
Chronic paranoia may be caused by brain
Paramedical damage, substance abuse (including alcohol
A generic title for the professions which work and cannbis), SCHIZOPHRENIA or severe
closely with or are reponsible to the medical DEPRESSION. Those affected may become con-
profession in caring for patients. A paramedical stantly suspicious and angry and tend to live
worker, coloquially called a paramedic, has an isolated existence, exhibiting difficult and
skills, experience and qualifications in certain odd behaviour. Often believing themselves to
spheres of health care. Examples are ambulance be normal, they do not seek treatment. If
crew primarily those trained to deal with treated early with antipsychotic drugs, they
emergencies; physiotherapists (see PHYSIO- often recover; if not, the delusions and
THERAPY); radiographers (see RADIOGRAPHER); accompanying erratic behaviour become
and dieticians (see DIETETICS). entrenched. (See MENTAL ILLNESS.)

Parameter Paraparesis
A measurement of a certain factor for A disorder or injury of the NERVOUS SYSTEM in
example, pulse rate, blood pressure, or haemo- which the affected individual suffers from
globin concentration that is relevant to a dis- weakness in both legs and sometimes of the
order under investigation. Often wrongly used muscles in the lower trunk. P
to describe the range of test results.
Paraphasia
Paramnesia Misplacement of words, or use of wrong words,
A derangement of the MEMORY in which words in speech as a result of a lesion in the speech
are used without a comprehension of their region of the BRAIN.
meaning; it is also applied to illusions of mem-
ory in which a person in good faith imagines Paraphimosis
and describes experiences which never occurred The constriction of the PENIS behind the glans
to him or her. by an abnormally tight foreskin that has been
retracted. The condition causes swelling and
Paranasal Sinus severe pain. Sometimes the foreskin can be
Sited within some of the bones of the SKULL, returned by manual manipulation after an ice
these are spaces filled with air and lined by pack has been applied to the glans or a topical
MUCOUS MEMBRANE. The sinuses comprise local anaesthetic applied. Sometimes an oper-
frontal and maxillary (a pair of each), ethmoidal ation to cut the foreskin is required.
(a group of small spaces), and two sphenoid
sinuses. They drain into the nasal cavities (see Paraphrenia
NOSE). When a person has an upper respiratory A form of PARANOIA. (See also MENTAL ILLNESS.)
infection, the sinuses sometimes become
infected: this causes pain, purulent discharge Paraplegia
from the nose and obstruction of the nasal pas- PARALYSIS of the lower limbs, accompanied gen-
sages (see SINUSITIS). Generally all that is erally by paralysis of bladder and rectum.
required is a decongestant and antibiotic but,
 536 Parapsychology

Parapsychology CORD through certain nerve centres in the mid-

The branch of PSYCHOLOGY that studies extra- brain, medulla, and lower end of the cord. The
sensory perception. This includes precognition nerves from these centres are carried in the
(seeing into the future); psychokinesis (a sup- third, seventh, ninth and tenth cranial nerves
posed ability of some people to move or change and the second, third and fourth sacral nerves.
the state of objects by thinking); telepathy The action of the parasympathetic system is
(communicating thoughts from one person to usually antagonistic to that of the sympathetic
another); and clairvoyance (the ability to visual- system. Thus it inhibits the action of the HEART
ise events at a distance). These phenomena have and augments the action of the INTESTINE;
no scientific explanation and some of these whereas the sympathetic augments the action of
abilities may be manifestations of mental ill- the heart and inhibits that of the intestine. (See
ness such as SCHIZOPHRENIA. diagram of sympathetic and parasympathetic
nervous systems under NERVOUS SYSTEM.)
Paraquat
A contact herbicide widely used in agriculture Parasympathomimetic
and horticulture. People using paraquat should A drug that stimulates the PARASYMPATHETIC
be careful to protect their eyes and skin so as NERVOUS SYSTEM. The actions of such drugs
not to come into contact with it: a mouthful is resemble those of ACETYLCHOLINE. Those
enough to kill, and the substance is involved in cholinergic actions include stimulation of mus-
around 40 suicides annually in the UK. Its culoskeletal muscle, reduction in the heart rate,
major misuse has resulted from its being greater tension in involuntary (or smooth)
decanted from the professional pack into soft- muscle, increasing glandular secretions such as
drink bottles and kept in the kitchen. Medical saliva, and constriction of the pupil of the EYE.
assistance should be obtained as soon as pos- MYASTHENIA GRAVIS, GLAUCOMA, certain dis-
sible, as some victims of poisoning may require orders of the cardiovascular system, and intes-
hospital inpatient care, including renal DIALY- tinal or bladder malfunction are among the
SIS. Several medical centres have been set up conditions for which cholinergic drugs are
throughout the country to provide treatment prescribed.
in cases of paraquat poisoning. Details of these
can be obtained from the National Poisons
Information Service. Parathion
One of the ORGANOPHOSPHORUS insecticides.
Parasite It is highly toxic to humans and must therefore
An organism which lives in or on another be handled with the utmost care.
P organism, known as the host. A parasite derives
all its nourishment from the host but provides Parathyroid
no benefits in return. It may damage the hosts The grouping of four small glands, about 5 mm
bodily functions and in extreme cases cause the in diameter, which lie to the side of and behind
death of the host. Human parasites include the THYROID GLAND. These glands regulate the
WORMS, fungi (see FUNGUS), BACTERIA and metabolism of calcium and of phosphorus. If
viruses (see VIRUS). for any reason there is a deficiency of the secre-
tion of the parathyroid glands, the amount of
Parasiticide calcium in the blood falls too low and the
A general term applied to agents or substances amount of phosphorus increases. The result is
destructive to parasites (see PARASITE). the condition known as TETANY characterised
by restlessness and muscle spasms sometimes
Parasuicide severe. The condition is checked by the injec-
Non-fatal self-poisoning or self-injury, or tion of calcium gluconate, which causes an
attempted suicide. It is most common in the increase in the amount of calcium in the blood.
1215 age group. As a rule, the intention is not The most common cause of this condition
to commit suicide but to sound a cry for help to (hypoparathyroidism) is accidental injury to or
resolve an acute domestic, social or personal removal of the glands during the operation of
upset. thyroidectomy for the treatment of Graves dis-
ease (see THYROID GLAND, DISEASES OF Thy-
Parasympathetic Nervous rotoxicosis). If there is over-production of the
System parathyroids, there will be an increase of cal-
That part of the AUTONOMIC NERVOUS SYSTEM cium in the blood: this extra calcium is drawn
which is connected with the BRAIN and SPINAL from the bones, causing cysts to form with
 Parkinsonism 537

resulting bone fragility. This cystic disease of rect proportion of essential (indispensable) and
bone is known as OSTEITIS FIBROSA CYSTICA. non-essential amino acids. Preparations are
Tumours of the parathyroid glands result in this available with or without electrolytes and with
overactivity of the parathyroid hormone, and or without fat emulsions.
the resulting increase in the amount of calcium The main hazards of intravenous feeding are
in the blood leads to the formation of stones in blood-borne infections made possible by con-
the kidneys. The only available treatment is tinued direct access to the circulation, and
surgical removal of the tumour. Increased activ- biochemical abnormalities related to the com-
ity of the parathyroid glands, or hyperparathy- position of the solutions infused. The continu-
roidism, may cause stones in the kidneys. (See ous use of hypertonic solutions of glucose can
KIDNEYS, DISEASES OF.) cause HYPERGLYCAEMIA and glycosuria and the
resultant POLYURIA may lead to dehydration.
Paratyphoid Fever Treatment with INSULIN is needed when hyper-
See ENTERIC FEVER. osmolality occurs, and in addition the water
and sodium deficits will require to be corrected.
Parenchyma
A term meaning originally all the soft tissues of Paresis
internal organs except their supporting struc- A state of partial PARALYSIS.
tures, although now reserved for the secreting
cells of the glandular organs. Parietal
The term applied to anything pertaining to the
Parenteral wall of a cavity: for example, parietal pleura,
Administration of drugs by any route other the part of the pleural membrane which lines
than by the mouth or by the bowel for the wall of the chest.
example, by intramuscular or intravenous
injection or infusion. Parietal Bone
Either one of a pair of bones that form the top
Parenteral Nutrition and sides of the cranium of the SKULL.
In severely ill patients especially those who
have had major surgery or those with SEPSIS, Parietal Lobe
burns, acute pancreatitis (see PANCREAS, DIS- A major section of each cerebral hemisphere (see
ORDERS OF) and renal failure the bodys BRAIN). The two lobes lie under the parietal
reserves of protein become exhausted. This bones and contain the sensory cortex.
results in weight loss; reduction in muscle mass;
a fall in the serum albumin (see ALBUMINS) and Parkinsonism P
LYMPHOCYTE count; and an impairment of cel- Parkinsonism, or paralysis agitans, is a progres-
lular IMMUNITY. Severely ill patients are unable sive disease of insidious onset usually occurring
to take adequate food by mouth to repair the in the second half of life; it is much more com-
body protein loss so that enteral or parenteral mon in men than in women. Degenerative
nutrition is required. Enteral feeding is through changes in the basal ganglia (see BASAL GAN-
the gastrointestinal tract with the aid of a naso- GLION) lead to a deficiency in the NEURO-
gastric tube; parenteral nutrition involves the TRANSMITTER, DOPAMINE or occasionally in
provision of carbohydrate, fat and proteins by other neurotransmitters and it is this
intravenous administration. deficiency that is responsible for most cases.
The preferred route for the infusion of The clinical picture is characterised by
hyperosmolar solutions is via a central venous TREMOR, rigidity and poverty of spontaneous
catheter (see CATHETERS). If parenteral nutrition movements. The loss of natural play of expres-
is required for more than two weeks, it is advis- sion in the face produces a mask-like expres-
able to use a long-term type of catheter such as sion. Rigidity of the larynx, tongue and lips
the Broviac, Hickman or extra-corporeal type, produces a flat, expressionless voice. The most
which is made of silastic material and is inserted common symptom is tremor, often affecting
via a long subcutaneous tunnel; this not only one hand, spreading to the leg on the same side,
helps to fix the catheter but also minimises the then to the other limbs. It is more pronounced
risk of ascending infection. in resting limbs and is exaggerated by excite-
Dextrose is considered the best source of ment, stopping during sleep. It may interfere
carbohydrate and may be used as a 20 per cent with eating and dressing. Limb rigidity leads to
or 50 per cent solution. AMINO ACIDS should be an increasing tendency to stoop. The patient has
in the laevo form and should contain the cor- a shuffling walk with a peculiar running gait.
 538 Paronychia

Treatment Several drugs are used to keep the Parotid Gland

condition under control. None is curative, all One of the SALIVARY GLANDS. It is situated just
have side-effects, and finding the most suitable in front of the ear, and its duct runs forwards
one for any individual depends largely on across the cheek to open into the interior of the
understanding cooperation between family mouth on a little projection opposite the sec-
doctor and patient. Dopaminergic and ond last tooth of the upper row. The parotid
antimuscarinic (see ANTIMUSCARINE) drugs are gland is generally the first of the salivary glands
used in treatment. Levodopa, a precursor of to become enlarged in MUMPS.
dopamine, is a long-used example of the for-
mer; it produces spectacular improvement in Parotitis
one-fifth and moderate improvement in two- Inflammation of the PAROTID GLAND caused by
fifths of patients. Benzhexol hydrochloride is infection or by many AUTOIMMUNE DIS-
one of several antimuscarinic drugs used in ORDERS. Epidemic parotitis is another name for
Parkinsons disease; selegiline is a monoamine- MUMPS.
oxidase inhibitor used in severe parkinsonism
in conjunction with levodopa to reduce end- Paroxetine
of-dose deterioration. Adverse effects include One of the ANTIDEPRESSANT DRUGS in the
HYPOTENSION, nausea and vomiting, confu- SELECTIVE SEROTONIN-REUPTAKE INHIBITORS
sion, and agitation. Some drugs used to treat (SSRIS) group. (See also MENTAL ILLNESS.)
other disorders produce Parkinsonian side-
effects. Patients seeking further advice and Paroxysm
help, together with their relatives, are advised A sudden temporary attack that may take the
to contact the Parkinsons Disease Society of form of a convulsion or spasm. It may also
the UK. occur when a patient with a disease suddenly
deteriorates.
Paronychia
The term applied to inflammation near the nail Parrot Disease
(see under SKIN). The infection, usually caused by See PSITTACOSIS.
Staphyloccous aureus (see STAPHYLOCOCCUS),
may affect the tissues around the nail, including Parthenogenesis
its root, and sometimes spreads to the pulp of Non-sexual reproduction. In other words,
the affected finger or toe. The tendons that run development of the OVUM into an individual
along the back of the infected digit may without fertilisation by a SPERMATOZOON. It is
occasionally become infected. Acute paronychia common in plants and has been produced in
P is the most common type, with local pain and animals experimentally.
tenderness and swelling of the nail fold. Treat-
ment is with ANTIBIOTICS or, if an ABSCESS Partogram
forms, local surgery to release any pus. Some- A method of recording the degree of dilatation,
times infection may be caused by a virus, or opening, of the cervix (or neck) of the
against which antibiotics are ineffective. If viral UTERUS in labour (see PREGNANCY AND
infection persists then antiviral drugs may LABOUR) to assess how labour is progressing.
eradicate it.
Chronic paronychia occurs with reinfection Parturition
of the nail bed. This is usually because the per- Labour see PREGNANCY AND LABOUR.
sons hands are regularly immersed in water,
making the skin vulnerable to infection. The Parvoviruses
finger should be kept dry and a dry dressing (from parvus, Latin for small) is a group of vir-
applied accompanied by a course of antibiotics uses responsible for outbreaks of WINTER
FLUCLOXACILLIN or a cephalosporin. VOMITING DISEASE. One strain is the cause
of ERYTHEMA infectiosum (slapped-cheek
Parosmia syndrome).
A perverted sense of SMELL; everything may
smell unpleasant to the affected individual. The PAS
most common cause is some septic condition of A commonly used abbreviation for PARA-AMINO
the nasal passages (see NOSE), but the condition SALICYLIC ACID.
may occasionally be due to a lesion in the BRAIN
involving the centre responsible for the sense of Passive Movement
smell. A movement induced by someone other than
 Pathogens 539

the patient. Physiotherapists (see PHYSIO- shaped somewhat like an oyster-shell, lying in
THERAPY) manipulate joints by passive move- the tendon of the extensor muscle of the thigh,
ment in order to retain and encourage function and protecting the knee-joint in front. (See also
of a nerve or muscle that is not working nor- KNEE.)
mally because of injury or disease.
Patellar Reflex
Pastes See REFLEX ACTION.
See OINTMENTS.
Patellar Tendinitis
Pasteurella Also known as jumpers knee. Inflammation of
A group of bacilli. They are essentially animal the tendon of the extensor muscle of the thigh,
parasites (see PARASITE) that under certain con- in which the PATELLA or knee-cap is secured.
ditions are transmitted to humans, and include Usually the result of injury or excessive use or
the micro-organism responsible for PLAGUE and stress for example, in athletic training symp-
TULARAEMIA. toms include pain, tenderness and sometimes
restricted movement of the parent muscle.
Pasteurisation Treatment may include NON-STEROIDAL ANTI-
A method of sterilising milk (see also MILK INFLAMMATORY DRUGS (NSAIDS), ULTRASOUND
Preparation of milk). In many parts of the treatment and PHYSIOTHERAPY, and, if persist-
world, pasteurisation has done away with milk- ent, injection of a corticosteroid drug (see COR-
borne infections, of which the most serious is TICOSTEROIDS) around the tendon.
bovine TUBERCULOSIS, affecting the glands,
bones and joints of children. Other infections Patent
conveyed by milk are SCARLET FEVER, DIPH- In the medical context, a term meaning open
THERIA, ENTERIC FEVER (typhoid and para- for example, patent DUCTUS ARTERIOSUS. The
typhoid), undulant fever (BRUCELLOSIS), and term is also used for proprietary MEDICINES
food poisoning (e.g. from CAMPYLOBACTER, or which, because of the research and cost
the toxins of the STAPHYLOCOCCUS). involved in producing many of them, are
protected by a patent. This means that without
High-temperature short-time (HTST) an agreement, no company or organisation
pasteurisation consists of heating the other than the patent-holder can produce the
milk at a temperature not less than 717 C substance.
(161 F) for at least 15 seconds, followed by
immediate cooling to a temperature of not Patent Ductus Arteriosus
more than 10 C (50 F). See DUCTUS ARTERIOSUS. P
Low-temperature pasteurisation, or Patho-
holder process, consists in maintaining the A prefix indicating relationship to a disease
milk for at least half an hour at a temperature for example, PATHOLOGY, a study of disease.
between 63 and 65 C (145150 F), followed
by immediate cooling to a temperature of not Pathogenesis
more that 10 C (50 F). This has the effect of The ways in which a disease or disorder starts
considerably reducing the number of bacteria and develops. The term applies in particular to
contained in the milk, and of preventing the the physiological and cellular activities that are
diseases conveyed by milk as referred to above. involved in the mode of origin and develop-
ment of the condition.
Patch Test
This is used to identify possible substances that Pathogenic
may be causing a patients ALLERGY. Small This term means disease-producing, and is a
amounts of different substances are placed on term applied, for example, to bacteria capable
the skin usually of the back or arm. If the of causing disease.
patient is allergic then a red flare and swelling
will appear, usually within about 15 minutes. Pathogens
Sometimes the reaction may take longer up to Micro-organisms that cause diseases, parasitis-
three days to develop. ing plants, animals and humans (see PARASITE).
Some organisms are frequently PATHOGENIC,
Patella whereas others rarely cause disease. Opportun-
Also known as the knee-cap, this is a flat bone istic pathogens are those which rarely cause
 540 Pathognomonic

serious infection in healthy people but can do Patient Empowerment

so in patients with weakened immune systems At a personal level, the engagement of indi-
(immunocompromised see IMMUNITY). viduals in decisions about their health and
Pathogens include BACTERIA, viruses (see about the diagnosis, treatment and after-care of
VIRUS), prions (see PRION), fungi (see FUNGUS), their illness, injuries and other disorders. At a
PROTOZOA and metazoa (multicellular micro- public level, the engagement of all members of
organisms called HELMINTHS or worms). The the public in the planning, provision and per-
pathogenicity of an organism is called its viru- formance of their health-care services. Trad-
lence, which is measured by the number of itionally, at both personal and public levels, the
organisms required to cause disease. The 50 per patient has generally been regarded as naturally
cent of lethal dose (LD50) is the quantity of a subordinate to the politicians and managers
particular pathogen needed to cause infection who plan and run the health-care system(s),
in half of the hosts invaded. and to health professionals and medical institu-
tions who provide personal health care. The
Pathognomonic public and patients are increasingly unwilling to
A term applied to signs or symptoms which are accept this traditional model and are asserting
especially characteristic of certain diseases, and themselves, for example through patient help
on the presence or absence of which the diag- groups, complaints, litigation and local political
nosis depends. Thus the discovery of the action with the aim of securing changes in how
Mycobacterium tuberculosis in the sputum is health care is organised and a much greater say
said to be pathognomonic of pulmonary in their own care.
tuberculosis.
Paul-Bunnell Test
Pathology A test for MONONUCLEOSIS which is based
The science which deals with the causes of, and upon the fact that patients with this disease
changes produced in the body by, disease. develop ANTIBODIES which agglutinate sheep
red blood cells.
Patient
A person with injury, physical or mental dis- Peak Flow Meter
order or disease, or abnormality who comes A device that measures the rate at which an
into the care of a health professional or of an individual can expel air from the LUNGS. This is
institution responsible for providing care to an indication of the reserve in the capacity of
such persons. Professions more politically cor- the lungs. Narrowed airways (bronchospasm)
rect than medicine have adopted the term cli- slow the rate at which air can be expelled; the
P ent perhaps due to a misunderstanding of the peak flow meter can assess the severity of the
meaning of the word, patient (I wait upon, i.e. I condition. ASTHMA causes bronchospasm and
consult). the device can measure the effectiveness of
treatment with BRONCHODILATOR drugs; this
should be done regularly to monitor the pro-
Patient Choice gress of the disease.
See ETHICS.
Pectin
Patient Consent A polysaccharide substance allied to STARCH,
See ETHICS. contained in fruits and plants, and forming the
basis of vegetable jelly. It has been used as a
Patient-Controlled Analgesia TRANSFUSION fluid in place of blood in cases of
A technique whereby a patient can deliver an haemorrhage and shock.
analgesic substance (see ANALGESICS) in
amounts related to the extent of the PAIN that Pectoral
he or she is suffering. For example, to combat Anything pertaining to the chest, or a remedy
post-operative pain, some hospitals use devices used in treating chest troubles.
which allow patients to give themselves small
intravenous amounts of opiates when they are Pectoriloquy
needed. Pain is more effectively controlled if it The resonance of the voice, when spoken or
is not allowed to reach a high level, a situation whispered words can be clearly heard through
which tends to happen when patients receive the stethoscope placed on the chest wall. It is a
analgesics only on ward drug rounds or when sign of consolidation, or of a cavity, in the
they ask the nursing staff for them. lung.
 Pelvic Inflammatory Disease (PID) 541

Pedicle Peduncle
A narrow tube of tissue formed by folded skin A stalk-like structure that usually acts as a
which links a piece of tissue used for surgical support.
grafting to its site of origin. A pedicle graft is
used by the surgeon usually a reconstructive/ Peer Review
plastic surgeon when the site under repair is The procedures used by doctors and scientists
unsuitable for an independent graft, usually to review the work, decisions and writings of
because the blood supply at the recipient site is their professional colleagues peer groups.
inadequate. (See RECONSTRUCTIVE (PLASTIC) Reviewers of scientific papers are commonly
SURGERY.) called referees, and papers submitted to medical
A pedicle is also found occurring between a and scientific journals for publication are cus-
tumour and its tissue of origin, and the term is tomarily reviewed by one or more experts in the
used in anatomy to refer to any slim tubular subject(s) dealt with in the paper. The aim is to
process. improve the quality of the study by pointing
out potential pitfalls or errors to the author(s),
Pediculocide or to assist medical-journal editors in deciding
A substance that kills Pediculosis capitis head which papers to prioritise for publication. Evi-
louse (see under PEDICULOSIS). dence that peer review is effective is mixed.
Applications for research grants are also usually
Pediculosis subjected to peer review. (See also RESEARCH
Infestation with lice, of which three species FRAUD AND MISCONDUCT.)
infect humans:
Pellagra
Pediculus humanus var. capitis (head A potentially fatal nutritional disorder caused
louse) affects the scalp in children or adults, by a deficiency of vitamin B complex (niacin).
particularly in females. The adult louse may The symptoms are DERMATITIS, diarrhoea and
visit many heads in one day, especially in DEMENTIA. The deficiency occurs mainly in
schoolgirls. It lays its eggs on the scalp hair and poor people in developing countries where
the resulting nit grows out with the hair. Sec- maize is a prime constituent of the diet. Nico-
ondary infection owing to scratching is com- tinic acid in maize is in a bound form that the
mon in severe infestations, causing enlarged consumer cannot utilise. Further, maize is
lymph glands in the posterior neck and some deficient in the amino acid, tryptophan, from
general debility. The lice and nits can be killed which the human body can make nicotinic acid
by applications of MALATHION 0.5 per cent (see AMINO ACIDS).
lotion or PERMETHRIN 1 per cent lotion. After P
the hair is washed, application of a conditioner Treatment The disease is prevented or cured
allows nits to be removed with a fine nit comb. by adding to the diet, foods such as fresh meat,
eggs, milk, liver, and yeast extracts, as well as
Pediculus pubis (crab louse) is broader and nicotinic acid in addition to improving the
shorter than the head louse and less mobile. general conditions of life.
Usually transmitted sexually, it is found in the
pubic area but may infect eyelashes and other Pelvic Inflammatory Disease
body hair. It is easily seen, as are the large nits (PID)
attached to the public hair: permethrin and An infection of the endometrium (membran-
malathion lotions are effective. eous lining) of the UTERUS, FALLOPIAN TUBES
and adjacent structures caused by the ascent of
Pediculus humanus var. corporis micro-organisms from the vulva and vagina.
(body louse) differs from the head and crab Around 100,000 women develop PID each year
louse in that it lives in clothing and only goes in the UK; most of those affected are under 25
on to the body to feed. Infestation is found in years of age. Infection is commonly associated
vagabonds, armies in the field, or prisoners in with sexual intercourse; Chlamydia trachomatis
conditions where even minimal hygiene is (see CHLAMYDIA) and Neisseria gonorrhoeae (see
impossible. The lice are found in the seams of NEISSERIACEAE) are the most common patho-
clothing together with multiple eggs. Typically gens. Although these bacteria initiate PID,
excoriation and pigmentation are seen on the opportunistic bacteria such as STREPTOCOCCUS
back of the infested person. Replacement of and bacteroides often replace them.
clothing or autoclaving or hot ironing of the The infection may be silent with no
clothes is curative. obvious symptoms or symptoms may be
 542 Pelvimetry

troublesome, for example, vaginal discharge Pemphigoid

and sometimes a palpable mass in the lower See PEMPHIGUS.
abdomen. If a LAPAROSCOPY is done usually
by endoscopic examination overt evidence of Pemphigus
PID is found in around 65 per cent of sus- Autoimmune disease of the SKIN in which the
pected cases. cells of the epidermis lose their adhesion to each
PID may be confused with APPENDICITIS, other, resulting in blister formation.
ECTOPIC PREGNANCY and PID is a common
cause of such pregnancies ovarian cyst (see Pemphigus vulgaris is a serious form
OVARIES, DISEASES OF) and inflammatory dis- affecting skin and MUCOUS MEMBRANE. It
orders of the intestines. Treatment is with a affects young and middle-aged people with
combination of ANTIBIOTICS that are active widespread blistering, erosion and crusting of
against the likely pathogens, accompanied by the skin. Extensive involvement of the lips,
ANALGESICS. Patients may become seriously ill mouth and throat interfere with nutrition.
and require hospital care, where surgery is Untreated, it is eventually fatal, but the disease
sometimes required if conservative manage- can now be controlled by large doses of oral
ment is unsuccessful. All women who have PID CORTICOSTEROIDS and other immunosuppres-
should be screened for sexually transmitted dis- sive drugs. MORBIDITY from the adverse effects
ease and, if this is present, should be referred of steroids is a serious problem, but some
with their partner(s) to a genito-urinary medi- patients are eventually cured.
cine clinic. Up to 20 per cent of women who
have PID become infertile, and there is a seven- Pemphigus foliaceus is seen in the eld-
to ten-fold greater risk of an ectopic pregnancy erly; the blistering is more superficial in the
occurring. epidermis. It may be very widespread, but is not
life-threatening because mucous membranes are
Pelvimetry not affected. Topical corticosteroids will some-
Measurement of the internal dimensions of times control the eruption, but in severe cases
the PELVIS. The four diameters measured are: treatment is as for pemphigus vulgaris.
transverse, anterioposterior, and left and right
oblique. These measurements help to establish Pemphigoid is a variant where the blistering
whether a fetus can be delivered normally. If occurs because of separation of the epidermis
the outlet is abnormally small, the mother and dermis. Mucosae are rarely affected and the
will have to be delivered by CAESAREAN disease affects mainly the arms and legs in the
SECTION. elderly. Treatment is as for pemphigus but
P smaller doses of corticosteroids usually suffice.
Pelvis
The bony pelvis consists of the two hip bones, Penicillamine
one on each side, with the sacrum and coccyx A metabolite of PENICILLIN which is one of the
behind. It connects the lower limbs with the CHELATING AGENTS. It is sometimes used in
spine. In the female it is shallower than in the RHEUMATOID ARTHRITIS that has not
male and the ilia are more widely separated, responded to the first-line remedies and it is
giving great breadth to the hips of the woman; particularly useful when the disease is compli-
the inlet is more circular and the outlet larger; cated by VASCULITIS. Penicillamine is also used
whilst the angle beneath the pubic bones (sub- as an antidote to poisoning by heavy metals,
pubic angle), which is an acute angle in the particularly copper and lead, as it is able to bind
male, is obtuse in the female. All these points these metals and so remove their toxic effects.
are of importance in connection with child- Because of its ability to bind copper it is also
bearing. used in WILSONS DISEASE where there is a
The contents of the pelvis are the urinary deficiency in the copper-binding protein so that
bladder and rectum in both sexes; in addition copper is able to become deposited in the brain
the male has the seminal vesicles and the pro- and liver, damaging these tissues.
state gland surrounding the neck of the bladder,
whilst the female has the womb, ovaries, and Penicillin
their appendages. The name given by Sir Alexander Fleming, in
A second meaning is as in renal pelvis that 1929, to an antibacterial substance produced by
part of the collecting system proximal to the the mould Penicillium notatum. The story of
URETER which collects urine from the renal penicillin is one of the most dramatic in the
pyramids (see KIDNEYS). history of medicine, and its introduction into
 Penis 543

medicine initiated a new era in therapeutics pensed to children have fallen by 95 per cent in
comparable only to the introduction of ANAES- the last ten years.
THESIA by Morton and Simpson and of ANTI- CARBENICILLIN, a semi-synthetic penicillin, this
SEPTICS by Pasteur and Lister. The two great must be given by injection, which may be pain-
advantages of penicillin are that it is active ful. Its main use is in dealing with infections
against a large range of bacteria and that, even due to Pseudomonas pyocanea. It is the only
in large doses, it is non-toxic. Penicillin diffuses penicillin active against this micro-organism
well into body tissues and fluids and is excreted which can be better dealt with by certain
in the urine, but it penetrates poorly into the non-penicillin antibiotics.
cerebrospinal fluid. PIPERACILLIN AND TICARCILLIN are carboxy-
Penicillin is a beta-lactam antibiotic, one of a penicillins used to treat infections caused by
group of drugs that also includes CEPHA- Pseudomonas aeruginosa and Proteus spp.
LOSPORINS. Drugs of this group have a four- FLUCLOXACILLIN, also a semi-synthetic peni-
part beta-lactam ring in their molecular struc- cillin, is active against penicillin-resistant
ture and they act by interfering with the cell- staphylococci and has the practical advantage of
wall growth of mutliplying bacteria. being active when taken by mouth.
Among the organisms to which it has been, TEMOCILLIN is another penicillinase-resistant
and often still is, active are: streptococcus, penicillin, effective against most gram-negative
pneumococcus, meningococcus, gonococcus, bacteria.
and the organisms responsible for syphilis and AMOXICILLIN is an oral semi-synthetic penicil-
for gas gangrene (for more information on these lin with the same range of action as ampicillin
organisms and the diseases they cause, refer to but less likely to cause side-effects.
the separate dictionary entries). Most bacteria MECILLINAM is of value in the treatment of
of the genus staphylococcus are now resistant infections with salmonellae (see FOOD POISON-
because they produce an enzyme called PENI- ING), including typhoid fever, and with E. coli
CILLINASE that destroys the antibiotic. A par- (see ESCHERICHIA). It is given by injection.
ticular problem has been the evolution of strains There is a derivative, pivmecillinam, which can
resistant to methicillin a derivative originally be taken by mouth.
designed to conquer the resistance problem. TICARCILLIN is a carboxypenicillin used mainly
These bacteria, known as METHICILLIN- for serious infections caused by Pseudomonas
RESISTANT STAPHYLOCOCCUS AUREUS (MRSA), aeruginosa, though it is also active against some
are an increasing problem, especially after major gram-negative bacilli. Ticarcillin is available
surgery. Some are also resistant to other anti- only in combination with clarulanic acid.
biotics such as vancomycin.
An important side-effect of penicillins is Penicillinase P
hypersensitivity which causes rashes and some- A bacterial ENZYME capable of neutralising the
times ANAPHYLAXIS, which can be fatal. antibacterial properties of PENICILLIN and other
beta-lactam antibiotics such as the CEPHA-
Forms of penicillin These include the LOSPORINS. Most staphylococci are now resist-
following broad groups: benzylpenicillin ant to benzylpenicillin because they produce
and phenoxymethyl-penicillin; penicillinase- this enzyme; cloxacillin, flucloxacillin and
resistant penicillins; broad-spectrum penicillins; temocillin are not inactivated.
antipseudomonal penicillins; and mecillinams.
BENZYLPENICILLIN is given intramuscularly, Penis
and is the form that is used when a rapid action The male organ through which the tubular
is required. URETHRA runs from the neck of the URINARY
PHENOXYMETHYLPENICILLIN (also called peni- BLADDER to the exterior at the meatus or open-
cillin V) is given by mouth and used in treating ing. URINE and SEMEN are discharged along the
such disorders as TONSILLITIS. urethra, which is surrounded by three cylin-
AMPICILLIN, a broad-spectrum antibiotic, is drical bodies of erectile tissue, two of which
another of the penicillins derived by semi- (corpora cavernosa) lie adjacent to each other
synthesis from the penicillin nucleus. It, too, is along the upper length of the penis and one
active when taken by mouth, but its special fea- (corpus spongiosum) lies beneath them. Nor-
ture is that it is active against gram-negative (see mally the penis hangs down in a flaccid state in
GRAMS STAIN) micro-organisms such as E. coli front of the SCROTUM. When a man is sexually
and the salmonellae. It has been superceded by aroused the erectile tissue, which is of spongy
amoxicillin to the extent that prescriptions for constituency and well supplied with small
ampicillin written by GPs in the UK to be dis- blood vessels, becomes engorged with blood.
 544 Pentamidine

This makes the penis erect and ready for inser- next to one another. Still more valuable evi-
tion into the womans vagina in sexual inter- dence is given by AUSCULTATION.
course. The end of the penis, the glans, is
covered by a loose fold of skin the foreskin or Percutaneous
PREPUCE which retracts when the organ is Any method of administering remedies by pass-
erect. The foreskin is sometimes removed for ing them through the SKIN, as by rubbing in an
cultural or medical reasons. ointment or applying a patch containing a
A common congenital disorder of the penis is drug.
HYPOSPADIAS, in which the urethra opens
somewhere along the under side; it can be Percutaneous Transhepatic
repaired surgically. BALANITIS is inflammation Cholangiopancreatography
of the glans and foreskin. (See also REPRO- (PTC)
DUCTIVE SYSTEM; EJACULATION; IMPOTENCE; A technique for displaying the bile ducts (see
PRIAPISM.) BILE DUCT) and pancreatic ducts (see PANCREAS)
with radio-opaque dyes. These are introduced
Pentamidine via a catheter (see CATHETERS) inserted into the
A drug that is used in the prevention and treat- ducts through an incision in the skin. An X-ray
ment of African trypanosomiasis (see SLEEPING is then taken of the area.
SICKNESS), and in the treatment of
LEISHMANIASIS. Percutaneous Transluminal
Coronary Angioplasty
Pepsin A treatment for a stenosed (restricted) coron-
An ENZYME found in the gastric juice which ary artery (see ARTERIES). A balloon-tipped
digests proteins, converting them into peptides catheter (see CATHETERS) is passed through an
(see PEPTIDE) and AMINO ACIDS. It is used in the incision in the skin of the chest into the artery
preparation of predigested foods (PEPTONISED of the HEART that has developed stenosis (nar-
FOODS), or, more frequently, taken orally after rowing). The balloon is aligned with the sten-
meals. Available as a white powder or liquid, it osed section and then inflated to dilate the
is prepared from the mucous membrane of cow, coronary artery and allow the blood to flow
sheep, or pig stomachs. more freely.

Peptic Ulcer Perforation

The term commonly applied to ulcers in the The perforation of one of the hollow organs of
stomach and duodenum. (See DUODENAL the abdomen or major blood vessels may occur
P ULCER; STOMACH, DISEASES OF.) spontaneously in the case of an ulcer or an
advanced tumour, or may be secondary to
Peptide trauma such as a knife wound or penetrating
A compound formed by the union of two or injury from a traffic or industrial accident.
more AMINO ACIDS. Whatever the cause, perforation is a surgical
emergency. The intestinal contents, which con-
Peptonised Foods tain large numbers of bacteria, pass freely out
Foods which have been predigested by PAN- into the abdominal cavity and cause a severe
CREATIN and thereby rendered more digestible. chemical or bacterial PERITONITIS. This is usu-
ally accompanied by severe abdominal pain,
Percussion collapse or even death. There may also be evi-
An aid to diagnosis practised by striking the dence of free fluid or gas within the abdominal
patients body with the fingers, in such a way as cavity. Surgical intervention, to repair the leak
to make it give out a note. It was introduced in and wash out the contamination, is often neces-
1761 by Leopold Auenbrugger (17221809) of sary. Perforation or rupture of major blood ves-
Vienna, the son of an innkeeper, who derived sels, whether from disease or injury, is an acute
the idea from the habit of his father tapping emergency for which urgent surgical repair is
casks of wine to ascertain how much wine they usually necessary. Perforation of hollow struc-
contained. According to the degree of dullness tures elsewhere than in the abdomen for
or resonance of the note, an opinion can be example, the heart or oesophagus may be
formed as to the state of CONSOLIDATION of caused by congenital weaknesses, disease or
air-containing organs, the presence of abnormal injury. Treatment is usually surgical but
cavities in organs, and the dimensions of solid depends on the cause.
and air-containing organs, which happen to lie
 Periosteum 545

Perfusion Perinatal Mortality

The transfer of fluid through a tissue. For Perinatal mortality consists of deaths of the
example, when blood passes through the lung FETUS after the 28th week of pregnancy and
tissue, dissolved oxygen perfuses from the deaths of the newborn child during the first
moist air in the alveoli to the blood. Fluid week of life. Today, more individuals die within
may also be deliberately introduced into a tis- a few hours of birth than during the following
sue by injecting it into the blood vessels sup- 40 years. It is therefore not surprising that the
plying the tissue. It is used as a sign of how perinatal mortality rate, which is the number of
adequate the circulation is at the time of ill- such deaths per 1,000 total births, is a valuable
ness. Poor peripheral perfusion, a sign of cir- indicator of the quality of care provided for the
culatory collapse or shock, is recognised by mother and her newborn baby. In 2002, the
pressing on the skin to force blood from capil- perinatal mortality rate was 7.87 in the United
laries. The time it takes for them to refill and Kingdom compared with 11.4 in 1982 and
the skin to become pink is noted: more than over 30 in the early 1960s.
5 seconds, and the circulation is likely to be The causes of perinatal mortality include
compromised. extreme prematurity, intrapartum anoxia (that
is, difficulty in the birth of the baby, resulting in
Peri- lack of oxygen), congenital abnormalities of the
A prefix meaning around. baby, and antepartum anoxia (that is, condi-
tions in the terminal stages of pregnancy pre-
Periarteritis Nodosa venting the fetus from getting sufficient oxygen).
See POLYARTERITIS NODOSA. The most common cause of perinatal death
is some complication of placenta, cord or
Pericarditis membranes. The next most common is con-
Acute or chronic inflammation of the PERI- genital abnormality. Intrauterine hypoxia and
CARDIUM, the membranous sac that surrounds birth asphyxia comprise the third most com-
the HEART. It may occur on its own or as part mon cause.
of PANCARDITIS, when inflammation also
affects the MYOCARDIUM and ENDOCARDIUM Perineum
(membranous lining of the inside of the Popularly called the crotch, or crutch, this is the
heart). Various causes include virus infection, region situated between the opening of the
cancer and URAEMIA. (See also HEART, DISEASES bowel behind and of the genital organs in front.
OF.) In women it becomes stretched in childbirth,
and the vaginal opening may tear or need to be
Pericardium cut (see EPISIOTOMY) to facilitate delivery of the P
The smooth membrane that surrounds the baby.
HEART.
Period
Perichondritis See MENSTRUATION.
Inflammation of CARTILAGE and the tissue sur-
rounding it, usually as a result of chronic Periodontal
infection. An adjective that relates to the tissues around
the TEETH.
Perimetritis
A localised inflammation of the PERITONEUM Periodontal Membrane
surrounding the UTERUS. See TEETH.

Perimetry Perioperative Cell Salvage

A test of the visual fields of the EYE that assesses A method of autologous blood TRANSFUSION
the extent of peripheral vision. The procedure using a patients own blood, salvaged during a
does not normally form part of a routine test of surgical operation instead of conventional
vision but can be of value in assessing neuro- blood-bank transfusion.
logical diseases such as tumour of the brain.
Periosteum
Perinatal The membrane surrounding a BONE. The peri-
A term applied to the period starting a few osteum carries blood vessels and nerves for the
weeks before birth, the birth itself and the week nutrition and development of the bone. When
or two following it. it is irritated, an increased deposit of bone takes
 546 Periostitis

place beneath it; if it is destroyed, the bone may are important measures. Surgery may be
cease to grow and a portion may die and separ- required.
ate as a sequestrum.
Peristalsis
Periostitis The worm-like movement by which the stom-
Periostitis means inflammation on the surface ach and bowels propel their contents. It consists
of a BONE, affecting the PERIOSTEUM. (See of alternate waves of relaxation and contraction
BONE, DISORDERS OF.) in successive parts of the intestinal tube. Any
obstruction to the movement of the contents
Peripheral-Blood Stem-Cell causes these contractions to become more for-
Transplants cible and are often accompanied by the severe
These have almost completely replaced BONE form of pain known as COLIC.
MARROW TRANSPLANT, used to treat malignan-
cies such as LEUKAEMIA and LYMPHOMA for the Peritoneoscopy
past 20 years. The high doses of CHEMO- See LAPAROTOMY.
THERAPY or RADIOTHERAPY used to treat these
diseases destroy the bone marrow which con- Peritoneum
tains stem cells from which all the blood cells The serous membrane of the abdominal cav-
derive. In 1989 stem cells were found in the ity. The parietal peritoneum lines the walls of
blood during recovery from chemotherapy. By the abdomen and the visceral peritoneum
giving growth factors (cytokines), the number covers the abdominal organs. The two are
of stem cells in the blood increased for about continuous with one another at the back of
three to four days. In a peripheral-blood stem- the abdomen and form a complicated closed
cell transplant, these cells can be separated from sac (see MESENTERY; OMENTUM). A small
the peripheral blood, without a general anaes- amount of fluid is always present to lubricate
thetic. The cells taken by either method are the membrane, while a large amount collects
then frozen and returned intravenously after the in conditions associated with OEDEMA or in
chemotherapy or radiotherapy is completed. PERITONITIS.
Once transplanted, the stem cells usually take
less than three weeks to repopulate the blood, Peritonitis
compared to a month or more for a bone mar- Inflammation of the PERITONEUM. It may be
row transplant. This means that there is less risk acute or chronic, localised or generally diffused,
of infection or bleeding during the recovery and its severity and danger may vary according
from the transplant. The whole procedure has a to the cause.
mortality risk of less than 5 per cent half the Acute peritonitis generally arises because
P risk of a bone marrow transplant. bacteria enter the peritoneal cavity, from pene-
trating wounds, e.g. stabs, from the exterior or
Peripheral Nervous System from the abdominal organs. Hence conditions
See NERVOUS SYSTEM.
leading to perforation of the STOMACH, INTES-
Peripheral Neuritis TINE, BILE DUCT, URINARY BLADDER, and other
Inflammation of the nerves (see NERVE) in the hollow organs such as gastric ulcer (see STOM-
outlying parts of the body. (See NEURITIS.) ACH, DISEASES OF), typhoid fever (see
ENTERIC FEVER), gall-stones (see under GALL-
Peripheral Vascular Disease BLADDER, DISEASES OF), rupture of the bladder,
The narrowing of the blood vessels in the legs strangulated HERNIA, and obstructions of the
and, less commonly, in the arms. Blood flow is bowels, may lead to peritonitis. Numerous bac-
restricted, with pain occurring in the affected teria may cause the inflammation, most com-
area. If the blood supply is seriously reduced, mon being E. coli, streptococci and the
GANGRENE of the tissues supplied by the gonococcus.
affected vessel(s) may occur and the limb may The symptoms usually begin with a RIGOR
need to be amputated. The common cause is together with fever, vomiting, severe abdominal
ATHEROSCLEROSIS which may be brought on by pain and tenderness. Shock develops and the
HYPERTENSION, excessively fatty diet, poorly abdominal wall becomes rigid. If untreated the
controlled DIABETES MELLITUS or smoking patient usually dies. Urgent hospital admission
the latter being the biggest risk factor, with 90 is required. X-ray examination may show gas in
per cent of affected patients having been mod- the peritoneal cavity. Treatment consists of
erate to heavy smokers. Stopping smoking is intravenous fluids, antibiotics and surgical
essential; adequate exercise and a low-fat diet repair of the causative condition. Such
 Personality Disorder 547

treatment, together with strong analgesics is damage from HYPOXIA or injury. Patients do
usually successful if started soon enough. not display any awareness of their surround-
ings, and are unable to communicate. Sleep
Peritonsillar Abscess alternates with apparent wakefulness, when
The term applied to a collection of pus or an some reflexes (see REFLEX ACTION) may be pres-
ABSCESS which occurs complicating an attack of ent: for example, patients eyes may reflexly fol-
TONSILLITIS. The collection of pus forms low or respond to sound, their limbs can
between the tonsil and the superior constrictor reflexly withdraw from pain, and their hands
muscle of the pharynx. This condition is also can reflexly grope or grasp. Patients can breathe
known as quinsy; treatment drainage of the spontaneously, and retain normal heart and
abscess and the administration of appropriate kidney function, although they are doubly
antibiotics. incontinent (see INCONTINENCE).
For a diagnosis of PVS to be made, the state
Permethrin should have continued for more than a prede-
Along with phenothrin, this is a largely non- fined period, usually one month. Half of
toxic pyrethroid insecticide, effective in SCABIES patients die within 26 months, but some can
and lice infestations. Resistance may develop to survive for longer with artificial feeding. To
these insecticides and also to MALATHION and assess a persons level of consciousness, a
CARBARYL, in which case topical treatment numerical marking system rated according to
should be alternated among the different various functions eye opening, motor and
varieties. verbal responses has been established called
the GLASGOW COMA SCALE.
Pernicious Anaemia The ETHICS of keeping patients alive with
An autoimmune disease in which sensitised artificial support are controversial. In the UK, a
lymphocytes (see LYMPHOCYTE) destroy the par- legal ruling is usually needed for artificial sup-
ietal cells of the STOMACH. These cells normally port to be withdrawn after a diagnosis of PVS
produce intrinsic factor, which is the carrier has been made. The chances of regaining con-
protein for vitamin B12 that permits its absorp- sciousness after one year are slim and, even if
tion in the terminal ileum. Without intrinsic patients do recover, they are usually left with
factor, vitamin B12 cannot be absorbed and this severe neurological disability.
gives rise to a macrocytic ANAEMIA. The skin PVS must be distinguished from conditions
and mucosa become pale and the tongue which appear similar. These include the
smooth and atrophic. A peripheral NEUR- LOCKED-IN SYNDROME which is the result of
OPATHY is often present, causing paraesthesiae damage to the brain stem (see BRAIN). Patients
(see under TOUCH), numbness and even ATAXIA. with this syndrome are conscious but unable to P
The more severe neurological complication of speak or move except for certain eye move-
sub-acute combined degeneration of the cord is ments and blinking. The psychiatric state of
fortunately more rare. The anaemia gets its CATATONIA is another condition in which the
name from the fact that before the discovery of patient retains consciousness and will usually
vitamin B12 it was uniformly fatal. Now a recover.
monthly injection of vitamin B12 is all that is
required to keep the patient healthy. Personality Disorder
Condition in which the individual fails to learn
Peroneal from experience or to adapt to changes. The
The name given to structures, such as the outcome is impaired social functioning and
muscles, and nerves, on the outer or fibular side personal distress. There are three broad over-
of the leg. lapping groups. One group is characterised by
eccentric behaviour with paranoid or schizoid
Perphenazine overtones. The second group shows dramatic
See PHENOTHIAZINES. and emotional behaviour with self-centredness
and antisocial behaviour as typical components
Perseveration of the disorder. In the third group, anxiety and
Perseveration is the senseless repetition of words fear are the main characteristics, which are
or deeds by a person with a disordered mind. accompanied by dependency and compulsive
behaviour. These disorders are not classed as
Persistent Vegetative State illnesses but psychotherapy and behavioural
(PVS) therapy may help. The individuals affected are
PVS may occur in patients with severe brain notoriously resistant to any help that is offered,
 548 Perspiration

tending to blame other people, circumstances of fever, in diabetes, and in some forms of
or bad luck for their persistent difficulties. (See glomerulonephritis (see KIDNEYS, DISEASES OF).
MENTAL ILLNESS; MULTIPLE PERSONALITY DIS- Some people are unable to sweat copiously, and
ORDER; MUNCHAUSENS SYNDROME.) are prone to HEAT STROKE.
EXCESSIVE SWEATING, OR HYPERIDROSIS, may
Perspiration be caused by fever, hyperthyroidism (see THY-
Commonly called sweat, it is an excretion from ROID GLAND, DISEASES OF), obesity, diabetes
the SKIN, produced by microscopic sweat- mellitus, or an anxiety state. Offensive perspir-
glands, of which there are around 25 million, ation, or bromidrosis, commonly occurs on the
scattered over the surface. There are two differ- hands and feet or in the armpits, and is due to
ent types of sweat-glands, known as eccrine and bacterial decomposition of skin secretions. A
apocrine. Insensible (that is unnoticed) perspir- few people, however, sweat over their whole
ation takes place constantly by evaporation body surface. For most of those affected, it is
from the openings of the sweat-glands, well the palmar and/or axillary hyperhidrosis that is
over a litre a day being produced. Sensible per- the major problem.
spiration (that is, obvious) to which the term Conventional treatment is with an ANTI-
sweat is usually confined occurs with phys- CHOLINERGIC drug. This blocks the action of
ical exertion and raised body temperature: up to ACETYLCHOLINE (a neurotransmitter secreted
3 litres an hour may be produced for short by nerve-cell endings) which relaxes some
periods. Normal sweating maintains the body involuntary muscles and tightens others, con-
within its customary temperature range and trolling the action of sweat-glands. But patients
ensures that the skin is kept adequately often stop treatment because they get an
hydrated for example, properly hydrated skin uncomfortably dry mouth. Aluminium chlor-
of the palm helps the effectiveness of a persons ide hexahydrate is a topical treatment, but this
normal grip. can cause skin irritation and soreness. Such
The chief object of perspiration is to main- antiperspirants may help patients with moder-
tain an even body temperature by regulating the ate hyperhidrosis, but those severely affected
heat lost from the body surface. Sweating is may need either surgery or injections of BOTU-
therefore increased by internally produced heat, LINUM TOXIN to destroy the relevant sympa-
such as muscular activity, or external heat. It is thetic nerves to the zones of excessive sweating.
controlled by two types of nerves: vasomotor,
which regulate the local blood flow, and secre- Perthes Disease
tory (part of the sympathetic nervous system) A condition of the hip in children, due to death
which directly influence secretion. and fragmentation of the epiphysis (or spongy
P extremity) of the head of the femur. The cause
Eccrine sweat is a faintly acid, watery fluid is not known. The disease occurs in the 410
containing less than 2 per cent of solids. The year age-group, with a peak between the ages of
eccrine sweat-glands in humans are situated in six and eight; it is ten times more common in
greatest numbers on the soles of the feet and boys than girls, and is bilateral in 10 per cent of
palms of the hands, and with a magnifying glass cases. The initial sign is a lurching gait with a
their minute openings or pores can be seen in limp, accompanied by pain. Treatment consists
rows occupying the summit of each ridge in the of limiting aggressive sporting activity which
skin. Perspiration is most abundant in these may cause intact overlying CARTILAGE to
regions, although it also occurs all over the loosen. Where there are no mechanical symp-
body. toms and MRI scanning shows that the cartilage
is intact, only minor activity modification may
Apocrine sweat-glands These start func- be necesssary but for several months or even
tioning at puberty and are found in the armpits, years. Any breach in the cartilage is dealt with at
the eyelids, around the anus in association with ARTHROSCOPY by fixing or trimming any loose
the external genitalia, and in the areola and flaps. Eventually the disease burns itself out.
nipple of the breast. (The glands that produce
wax in the ear are modified apocrine glands.) Pertussis
The flow of apocrine sweat is evoked by emo- Another name for WHOOPING-COUGH.
tional stimuli such as fear, anger, or sexual
excitement. Pes Cavus
Known popularly as claw-foot, this is a deform-
Abnormalities of perspiration De- ity in which the foot has an abnormally high
creased sweating may occur in the early stages arch and the tips of the toes are turned under.
 Phaeochromocytoma 549

Pes cavus may be present at birth or it can be Petri Dishes

caused by disruption of or damage to the blood Shallow, circular glass dishes, usually 10 cm in
and nerve supplies to the foot muscles. The use diameter, which are used in bacteriology labora-
of a specially made insole in the shoe may help, tories for the growth of micro-organisms.
but surgery is sometimes needed.
PET Scanning
Pes Planus Positron-emission tomography is a NUCLEAR
The technical name for FLAT-FOOT. MEDICINE diagnostic technique that works by
identifying positrons positively charged elec-
Pessaries trons given off by substances labelled with
(1) A plastic device placed in the VAGINA radioactive varieties of elements. The result is
designed to support a displaced UTERUS. three-dimensional images that identify meta-
(2) A suppository suitably shaped for insertion bolic and chemical activities of tissues, espe-
into the vagina. Made of oil of theobromine or cially brain tissues. The images provide
a glycerin basis, they are used for applying local information about tissue and organ functions,
treatment to the vagina. and can be collated with structural images using
COMPUTED TOMOGRAPHY or magnetic reson-
Pesticides ance imaging (MRI). The equipment is very
Any substance or mixture of substances expensive and available only in selected hos-
intended for preventing or controlling pitals in the United Kingdom. The technique is
unwanted species of plants and animals. This especially valuable in the assessment of neuro-
includes any substances intended for use as logical disorders.
plant-growth regulators, defoliants or desic-
cants. The main groups of pesticides are: herbi- Peyers Patches
cides to control weeds; insecticides to control Peyers patches are conglomerations of lymph-
insects; and fungicides to control or prevent oid nodules in the ileum, or lower part of the
fungal disease. small INTESTINE. They play an important part
in the defence of the body against bacterial
invasion, as in typhoid fever (see ENTERIC
Petechiae FEVER).
Small red MACULES due to haemorrhage in the
skin. They may be caused by trauma such as Peyronies Disease
by tight pressure, as in strangulation or even Painful and deformed erection of the PENIS
by the effect of violent coughing. Bleeding and caused by the formation of fibrous tissue. The
clotting disorders may provoke petechiae, and cause is unknown but it may be associated with
they are a feature of many childhood viral infec- P
DUPUYTRENS CONTRACTURE. The condition
tions. Most importantly they may be a sign of may be improved by surgery.
SEPTICAEMIA due to a meningococcus (see
NEISSERIACEAE).
pH
A measurement of the concentration of hydro-
Pethidine Hydrochloride gen ions in a solution that is calculated as a
A synthetic analgesic and antispasmodic drug, negative logarithm. A neutral solution has a pH
which is used in the treatment of painful and of 70 and this figure falls for a solution with
spasmodic conditions in place of morphine and increasing acidity and rises if the alkalinity
atropine. A prompt but short-lasting analgesic, increases. Measuring the pH of arterial blood
it has less of a constipating effect than mor- has a major role in managing serious respiratory
phine but is less potent. Useful for analgesia or cardiac disease including SHOCK and
during childbirth because it produces less SEPTICAEMIA.
respiratory depression in the baby than other
opioids. Pethidine is one of the CONTROLLED Phaeochromocytoma
DRUGS. A disorder in which a vascular tumour of the
adrenal medulla (see ADRENAL GLANDS)
Petit Mal develops. The tumour may also affect the struc-
An out-of-date term for less severe type of epi- turally similar tissues associated with the chain
leptic seizure (see EPILEPSY) that occurs usually of sympathetic nerves. There is uncontrolled
in children or adolescents but less often in and irregular secretion of ADRENALINE and
adults. The type of seizure is now referred to as NORADRENALINE with the result that the
an absence attack. patient suffers from episodes of high blood
 550 Phagocyte

pressure (HYPERTENSION), raised heart rate, and sell over-the-counter (OTC) drugs, providing,
headache. Surgery to remove the tumour may where appropriate, advice on their use. (See also
be possible; if not, drug treatment may help. MEDICINES.)
Pharmacists work in hospitals (NHS and
Phagocyte private) and in community pharmacies, as well
Cells including monocytes (a variety of as in the pharmaceutical industry where they
LEUCOCYTES) in the blood and macrophages conduct research and prepare and test pharma-
(see MACROPHAGE) in the tissues that envelop ceutical products. They have particular expert-
and digest BACTERIA cells, cell debris and other ise on the use of drugs: for instance, the way in
small particles. Phagocytes are an essential part which one medicinal compound can affect
of the bodys defence mechanisms. another and their possible adverse effects; and
they advise doctors and patients on these
Phagocytosis aspects. The NHS is also encouraging com-
A process by which BACTERIA and other foreign munity pharmacists to offer the public advice
particles in the body are ingested by monocytes on the treatment of simple illnesses such as
in the blood and macrophages in the tissues (see coughs, colds, headaches and stomach upsets.
under PHAGOCYTE) that envelop and digest bac- Hospital pharmacists are salaried employees of
teria, cells, cell debris and other small particles. the NHS but community pharmacists enter
Phagocytes are an essential part of the bodys into contract with the service, the terms of
defence mechanisms. which are negotiated centrally between phar-
macists representatives and the health depart-
Phalanx ments. Hospital pharmacists are now invited by
(Plural: phalanges.) The name given to any one the COMMITTEE ON SAFETY OF MEDICINES
of the small bones of the fingers and toes. The (CSM) to report suspected adverse drug reactions
phalanges are 14 in number in each hand and under the Yellow Card scheme in the same
foot the thumb and great toe possessing only way as doctors.
two each, whilst each of the other fingers and
toes has three. Pharmacogenetics
See PHARMACOGENOMICS.
Phallus
An alternative name for the PENIS, this word Pharmacogenomics
may also be used to describe a penis-like object. Also called pharmacogenetics the use of
In embryology the phallus is the rudimentary human genetic variations to optimise the dis-
penis before the urethral duct has completely covery and development of drugs and the
P developed. treatment of patients. The human race varies
much more in its genetic make-up than has
Phantasy previously been realised; these variations in
The term applied to an imaginary appearance GENES and their PROTEIN products could be
or daydream. utilised to provide safer and more effective
drugs. Genes affect drug absorption, distribu-
Phantom Limb tion, METABOLISM and excretion. Drugs are
Following the AMPUTATION of a limb, it is usual designed and prescribed on the basis of a popu-
for the patient to experience sensations as if the lations needs, but patients comprise a diverse
limb were still present. This condition is range of individuals. For example, nearly one-
referred to as a phantom limb. In most patients third of patients fail to respond to the
the sensation passes off in time. cholesterol-reducing group of drugs, the STAT-
INS. Around half do not respond to the tricyclic
Pharmacists ANTIDEPRESSANT DRUGS. Over 80 per cent of
Health professionals trained in the preparation patients responses to drugs depends on their
and dispensing of medicines; in England, Scot- genetics: this genetic variation needs to be iden-
land and Wales they are registered (after acquir- tified so as to make the prescription of drugs
ing the relevant professional qualifications) by more effective, and technology for analysing
the Royal Pharmaceutical Society. Northern Ire- genetic variants is progressing. Assessing drug
land has its own registration body. Registered effectiveness, however, is not simple because the
pharmacists are a vital branch of health care. health and diets of individuals are different and
They dispense P (pharmacy-only) and POM this can affect the response to a drug. Even so,
(prescription-only medicines) products; those the genetic identification of people who would
working in community (retail) pharmacies also or would not respond to a particular drug
 Phenindione 551

should benefit patients by ensuring a more Pharmacy

accurately targeted drug and by reducing the The term applied to the practice of preparing
risks to a person of side-effects from taking a and compounding medicines, or to a place
drug that would not work. There would also be where this is carried out.
substantial economic savings.
Pharyngitis
Pharmacokinetics An inflammatory condition affecting the wall
The way in which the body deals with a of the PHARYNX or the throat proper. It is most
drug. This includes the drugs absorption, commonly due to a viral upper respiratory tract
distribution in the tissues, METABOLISM, and infection, and may be confined to the pharynx
excretion. or may also involve the rest of the upper respira-
tory tract i.e. the nose and the larynx. The
Pharmacology mucous membrane is red and glazed with
The branch of science that deals with the dis- enlarged lymph-follicles scattered over it. The
covery and development of drugs. Those work- patients throat feels sore and swallowing may
ing in it (pharmacologists, doctors, scientists be uncomfortable. Only symptomatic treat-
and laboratory technicians) determine the ment, such as the use of analgesic drugs or
chemical structure and composition of drugs lozenges and gargles, is necessary for viral
and how these act in the body. They assess the pharyngitis, which usually is a stage in the
use of drugs in the prevention and treatment of development of a cold, or (less often, but more
diseases, their side-effects and likely toxicity. seriously) INFLUENZA. MONONUCLEOSIS may
This work takes place in universities, hospitals also start with pharyngitis. Streptococcal bac-
and, in particular, the pharmaceutical industry. teria linked to SCARLET FEVER also cause the
The latter has expanded tremendously during condition.
the 20th century and in Britain it is now one of
the largest business sectors, not only providing Pharynx
the NHS with most of its pharmaceutical Another name for the throat. The term throat is
requirements but also exporting many medi- popularly applied to the region about the front
cines to other countries. of the neck generally, but in its strict sense it
Pharmacologists not only research for new means the irregular cavity into which the nose
drugs, but also look for ways of synthesising and mouth open above, from which the larynx
them on a large scale. Most importantly, they and gullet open below, and in which the chan-
organise with clinicians the thorough testing of nel for the air and that for the food cross one
drugs to ensure that these are safe to use, add- another. In its upper part, the EUSTACHIAN
itionally helping to monitor the effects of drugs TUBES open one on either side, and between P
in regular use so as to identify unforeseen side- them on the back wall grows a mass of glandu-
effects. Doctors and hospital pharmacists have a lar tissue adenoids (see NOSE, DISORDERS OF).
special reporting system (Yellow Cards) under
which they notify the governments MEDICINES Phenazocine Hydrobromide
CONTROL AGENCY of any untoward con- A powerful analgesic which can be given under
sequences of drug treatments on their patients the tongue if nausea and vomiting are a
(see also MEDICINES). problem.

Pharmacopoeia Phenelzine
An official publication dealing with the recog- An example of the widely used ANTIDEPRES-
nised drugs and giving their doses, prepar- SANT DRUGS which are classified as MONO-
ations, sources, and tests. Most countries have a AMINE OXIDASE INHIBITORS (MAOIS). The drug
pharmacopoeia of their own. That for Great is particularly useful because its stimulant effect
Britain and Ireland is prepared by the British is less than that of most other MAOIs.
Pharmacopoeia Commission under the direc-
tion of the Medicines Commission. Many Phenindione
hospitals and medical schools have a small A synthetic anticoagulant (see ANTICOAGU-
pharmacopoeia of their own, giving the pre- LANTS). Given by mouth, it is used to prevent
scriptions most commonly dispensed in that the formation of clots in the blood in rheumatic
particular hospital or school. The British heart disease and atrial fibrillation (see HEART,
National Formulary is a compact authoritative DISEASES OF); as prophylaxis after insertion of a
volume for those concerned with the prescribing prosthetic heart valve; and as prophylaxis and
or dispensing of medicines. treatment of venous thrombosis and pulmonary
 552 Phenobarbitone

embolism. It is slower in action than WARFARIN, Phenothrin

not achieving its full anticoagulant effect until See PERMETHRIN.
up to 48 hours after the initial dose. The drug
should be avoided in patients with renal or hep- Phenotype
atic impairment, and whenever severe hyper- An individuals characteristics as determined by
sensitivity reactions have previously occurred. the interaction between his or her genotype
Adverse effects include rashes, fever, LEUCOPE- quota of GENES and the environment.
NIA, AGRANULOCYTOSIS, diarrhoea and pink
urine; breast feeding should be avoided. Phenoxybenzamine
An alpha-adrenoceptor blocking drug (see
Phenobarbitone ADRENERGIC RECEPTORS) used in the treatment
The British Pharmacopoeia name for one of the of HYPERTENSION caused by PHAEO-
most widely used of all the group of drugs CHROMOCYTOMA.
called BARBITURATES. It was mainly used in
combination with PHENYTOIN SODIUM as an Phenoxymethylpenicillin
anticonvulsant drug in the control of EPILEPSY, See under PENICILLIN.
but has been superceded largely by newer and
safer anti-epileptic drugs. Phenylalanine
A natural amino acid (see AMINO ACIDS) essen-
Phenol tial for growth in infants, and for nitrogen
Another name for CARBOLIC ACID. metabolism in adults.

Phenothiazines Phenylketonuria
A group of major antipsychotic drugs, colloqui- Commonly referred to as PKU, this is one of
ally called TRANQUILLISERS, widely used to the less common, but very severe, forms of
treat psychoses (see PSYCHOSIS). They can be mental deficiency. The incidence in popula-
divided into three main groups. Chlorpromaz- tions of European origin is around 1 in 15,000
ine, methotrimeprazine and promazine are births. The condition is due to the inability of
examples of group 1, usually characterised by the baby to metabolise the amino acid, phenyl-
their sedative effects and moderate antimus- alanine (see AMINO ACIDS). In the UK, every
carinic and extrapyramidal side-effects. Group newborn baby is screened for PKU by testing a
2 includes pericyazine, pipothiazine and thiori- spot of their blood collected by the midwife. A
dazine, which have moderate sedative effects positive diagnosis leads to lifelong treatment
but significant antimuscarinic action and mod- with a diet low in phenylalanine, with a good
P est extrapyramidal side-effects. Fluphenazine, chance that the infant will grow up mentally
perphenazine, prochlorperazine and trifluo- normal. Parents of children with phenyl-
perazine comprise group 3. Their sedative effects ketonuria can obtain help and information
are less than for the other groups and they have from the National Society for Phenylketonuria
little antimuscarinic action; they have marked (UK) Ltd. (See also METABOLIC DISORDERS;
extrapyramidal side-effects. GENETIC DISORDERS Recessive genes.)

Uses Phenothiazines should be prescribed Phenytoin Sodium

and used with care. The drugs differ in pre- An older drug for the treatment of EPILEPSY. It
dominant actions and side-effects; selection is not now widely used, as it is difficult to
depends on the extent of sedation required and determine the precise dose to avoid ill-effects
the susceptibility of the patient to extrapyrami- and long-term use leads to changes to the facial
dal side-effects. The differences between the appearance. However, the drug is still used for
drugs, however, are less important than the the quick control of an apparently uncontrol-
variabilities in patients responses. Patients lable epileptic fit, and after head injury or
should not be prescribed more than one anti- neurosurgery.
psychotic drug at a time. In the short term these
therapeutically powerful drugs can be used to Pheromones
calm disturbed patients, whatever the under- Chemicals produced and emitted by an indi-
lying condition (which might have a physical or vidual which produce changes in the social or
psychiatric basis). They also alleviate acute anx- sexual behaviour when perceived by other indi-
iety and some have antidepressant properties, viduals of the same species. The precise role of
while others worsen DEPRESSION (see also MEN- these odours for it is by their smell that they
TAL ILLNESS). are recognised in humans is still not clear, but
 Phospholipid 553

there is growing evidence of the part they play phobophobia (fear of phobias) and triskaideka-
in the animal kingdom. Thus, if a strange male phobia (fear of having 13 sitting at table).
rat is put into a group of female rats, this may Phobia is a form of obsession, and not
cause death of the fetus in any pregnant rats, uncommonly one of the features of anxiety.
and this is attributed to the pheromones Treatment is behavioural therapy comple-
emitted by the male rat. mented in some patients with ANTIDEPRESSANT
DRUGS. Care is needed, as some sufferers can
Phimosis become psychologically dependent on the drugs
Tightness of the foreskin (PREPUCE) which pre- used to treat them (see DEPENDENCE). Those
vents it from being pulled back over the under- who suffer from what can be a most distressing
lying head (glans) of the PENIS. Some phimosis condition can obtain help and advice from the
is normal in uncircumcised males until they are Phobics Society. (See also MENTAL ILLNESS.)
six months old. The condition may, however,
persist, eventually causing problems with urin- Phocomelia
ation. BALANITIS may occur because the inside This is a great reduction in the size of the prox-
of the foreskin cannot be properly washed. imal parts of the limbs. In extreme cases the
There may be an increased risk of cancer of the hands and feet may spring directly from the
penis. In adolescents and adults with phimosis, trunk. A rare condition, it occurred most com-
erection of the penis is painful. CIRCUMCISION monly in children whose mothers took THAL-
is the treatment. IDOMIDE in early pregnancy.

Phlebitis Pholcodine
Inflammation of a vein. (See VEINS; VEINS, DIS- An OPIOID cough suppressant similar to
EASES OF.) CODEINE; it is not, however, potent enough to
suppress severe coughs and is also constipating.
Phlebography
The study of the VEINS, particularly by means Phonation
of X-rays after the veins have been injected with The production of vocal sounds in particular,
a radio-opaque substance. speech.

Phlebolith Phonocardiograph
The term applied to a small stone formed in a An instrument for the graphic recording of
vein (see VEINS) as a result of calcification of a heart sounds and murmurs.
THROMBUS.
Phosphates P
Phlebotomy Salts of phosphoric acid. As this substance is
A traditional name for the operation of blood- contained in many articles of food as well as in
letting by opening a vein. (See VEINS; bone, the nuclei of cells, and the nervous sys-
VENESECTION.) tem, phosphates are constantly excreted in the
URINE. The continued use of an excess of food
Phlegm containing alkalis, such as green vegetables, and
A popular name for MUCUS, particularly that still more the presence in the urine of bacteria
secreted in the air passages. (See BRONCHITIS; which lead to its decomposition, produce the
EXPECTORANTS.) necessary change from the natural mild acidity
to alkalinity, and lead to the deposit of phos-
Phlyctenule phates and to their collection into stones.
A HYPERSENSITIVITY reaction of the con-
junctiva (see EYE). At the turn of the century the Phosphaturia
most common cause was TUBERCULOSIS; now- The presence in the URINE of a large amount of
adays it is most commonly due to hypersensitiv- PHOSPHATES.
ity to staphylococci (see STAPHYLOCOCCUS).
Phospholipid
Phobia A LIPID, the molecule of which contains a
An irrational fear of particular objects or situ- chemical derivative of PHOSPHORUS called
ations. A well-known American medical dic- phosphate. This type of lipid, which includes
tionary lists more than 200 examples of cephalins, lecithins and plasmalogens, is found
phobias, ranging, alphabetically, from fear of air in all tissues and organs, especially the BRAIN.
to fear of writing. Included in the list are Phospholipids are produced in the LIVER and
 554 Phosphorus

and take part in many of the bodys metabolic ing reactions. Psoralens induce erythema and
activities (see METABOLISM). pigmentation. AMIODARONE also induces pig-
mentation. (See also PHOTOCHEMOTHERAPY.)
Phosphorus
A non-metallic element whose compounds are Phytophotodermatitis is a streaky, blis-
widely found in plant and animal tissues. In tering photodermatosis typically seen on the
humans, this element is largely concentrated in limbs of children playing in grassy meadows in
BONE. Some phosphorus-containing com- summer. The phototoxic reaction is caused by
pounds such as ADENOSINE TRIPHOSPHATE psoralens in weeds.
(ATP) and creatine phosphate are essential parti-
cipants in the conversion and storage of energy Berlocque dermatitis is a pattern of
that are part of the bodys METABOLISM. Pure streaky pigmentation usually seen on womens
phosphorus is toxic. necks, caused by a reaction to psoralens in
perfumes.
Phosphorus Burns Certain rare metabolic diseases may lead to
Phosphorus compounds are used in chemical photosensitisation. They include the PORPHY-
laboratories, some industrial processes, RIAS and PELLAGRA. Other skin diseases such as
matches, fireworks and in certain types of aerial lupus erythematosus (see under LUPUS) and
bombs and artillery shells. If particles of phos- ROSACEA may be aggravated by light exposure.
phorus settle on or become embedded in the Sometimes, in the absence of any of these fac-
skin, the resulting burn should be treated with a tors, some people spontaneously develop a sen-
2 per cent solution of sodium bicarbonate, fol- sitivity to light causing various patterns of
lowed by application of a 1 per cent solution of DERMATITIS or URTICARIA. The most common
copper sulphate. pattern is polymorphic light eruption which
typically appears within a day or two of arrival
Photochemotherapy at a sunny holiday destination and persists until
A form of treatment in which deliberate departure. Continuously exposed areas, such as
exposure to a photosensitising drug and ultra- the hands and face, may be hardened and
violet light benefits certain skin diseases, par- unaffected.
ticularly PSORIASIS and T-cell LYMPHOMA. A
psoralen is the photoactive agent which reacts
with long-wave ultraviolet light (UVA), giving
Treatment Appropriate clothing and head-
gear, sunscreen creams and lotions are the main
the acronym, PUVA therapy.
preventative measures.
P Photocoagulation
Coagulation of the tissues of the retina (see EYE) Photodynamic Therapy
by laser, for treatment of diseases of the retina This comprises a photosensitising agent (one
such as diabetic retinopathy (see under EYE, DIS- activated by light), which accumulates in
ORDERS OF Retina, disorders of ). malignant tissue, and a source of light that
activates the photosensitiser, triggering it to
Photodermatoses generate highly reactive oxygen compounds
Diseases of the SKIN for which sunlight is par- that destroy malignant cells. One such photo-
tially or wholly responsible. In sufficient dos- sensitiser is temoporfin. Photodynamic therapy
age, short-wave ultraviolet light (UVB see is used to treat various types of malignancy; a
ULTRAVIOLET RAYS (UVR)) always causes ERY- recognised complication is photosensitivity,
THEMA. Higher doses progressively cause when a patient may suffer burns after transient
OEDEMA and blistering; this is acute sunburn. exposure to sunlight. Photodynamic therapy is
Graduated exposure to UVB causes pigmenta- increasingly used and photosensitivity reactions
tion (tanning). Prolonged chronic exposure to may also become more common.
sunlight eventually accelerates ageing of the
exposed skin with LENTIGO formation and loss Photophobia
of COLLAGEN and elastic tissue. After decades of Sensitivity to light. It can occur in MIGRAINE,
such exposure, epidermal DYSPLASIA and CAN- disorders of the eye, or in MENINGITIS.
CER may supervene.
Drugs given orally or topically may induce Photopsia
phototoxic reactions of various types. Thus, This is a description of the flashing lights which
TETRACYCLINES exaggerate sunburn reactions. are a not uncommon AURA preceding an attack
and the diuretic FRUSEMIDE may cause blister- of MIGRAINE.
 Physostigmine 555

Photosensitivity Physical Examination

Abnormal reaction to sunlight. The condition That part of a patients consultation with a doc-
usually occurs as a skin rash appearing in tor in which the doctor looks, feels (palpates)
response to light falling on the skin, and it and listens to (auscultates) various parts of the
may be caused by substances that have been patients body. Along with the history of the
eaten or applied to the skin. These are called patients symptoms, this enables the doctor to
photosensitisers and may be dyes, chemicals in assess the patients condition and decide
soaps, or drugs. Sometimes plants act as pho- whether an immediate diagnosis is possible or
tosensitisers for example, buttercups and whether laboratory or imaging investigations
mustard. The condition may occur in some are needed to reach a diagnosis. A full physical
illnesses such as lupus erythematosus (see under examination may take 30 minutes or more.
LUPUS). Physical examination, along with certain stand-
ard investigations, is done when a person
Photosynthesis attends for a preventive check-up of his or her
The method by which green plants and some state of health.
bacteria produce CARBOHYDRATE from water
and carbon dioxide. They use energy absorbed Physical Medicine
from the suns rays by a green pigment in the A medical specialty founded in 1931 and rec-
organism called chlorophyll. Photosynthesis is ognised by the Royal College of Physicians of
one of the earths fundamental biological pro- London in 1972. Physical-medicine specialists
cesses. As well as converting the carbon dioxide started by treating rheumatic diseases; sub-
into the essential biological compound carbo- sequently their work developed to include the
hydrate, the process removes the gas from the diagnosis and rehabilitation of people with
atmosphere where, if it builds to excess, the physical handicaps. The specialty has now been
atmospheric temperature rises, thus contribut- combined with that of RHEUMATOLOGY. (See
ing to global warming. also PHYSIOTHERAPY.)

Phrenic Nerve Physician-Assisted Suicide

The NERVE which chiefly supplies the DIA- See SUICIDE.
PHRAGM. A phrenic nerve arises on each side of
the SPINAL CORD from the third, fourth and Physiology
fifth cervical spinal nerves; both follow a long Physiology is the branch of medical science that
course down the neck, and through the chest to deals with the healthy functions of different
the diaphragm. They play a key part in RESPIR- organs, and the changes that the whole body
ATION through control of the diaphragm. undergoes in the course of its activities. The P
Injury to one nerve paralyses one half of the teaching of physiology is a basic part of the
diaphragm. Occasionally the phrenic nerve may medical students initial education.
be surgically crushed as part of the treatment to
repair a HIATUS HERNIA or, rarely, to stop Physiotherapy
intractable hiccups. An important treatment involving the use of
physical measures, such as exercise, heat,
Phrenology manipulation and remedial exercises in the
A quack method, common in the Victorian era, treatment of disease. An alternative name is
allegedly to study the mind and character of PHYSICAL MEDICINE. It is an essential part of the
individuals from the shape of the head. As the rehabilitation of convalescent or disabled
shape of the head has been shown to depend patients. Those who practise physiotherapy
chiefly upon accidental characteristics, such as physiotherapists have a recognised training
the size of the air spaces in the bones, and not and, on successful completion of this, are
upon development of special areas in the con- placed on the professions official register (see
tained brain, there is no scientific basis for the APPENDIX 8: PROFESSIONAL ORGANISATIONS.)
practice.
Physostigmine
Phthisis Also known as eserine. An alkaloid (see ALKAL-
A historical term means wasting, and was OIDS) obtained from Calabar bean, the seed of
applied to that progressive enfeeblement and Physostigma venenosum, a climbing plant of
loss of weight that arose from tuberculous dis- West Africa. Its action depends on the presence
ease of all kinds, but especially from the disease of two alkaloids, the one known as physostig-
as it affected the lungs (see TUBERCULOSIS). mine or eserine, the other as calabarine, the
 556 Phytomenadione

former of these being much the more images within and between hospitals and com-
important. munity health-care units, providing fast access
and remote working that will benefit patients
Action Physostigmine produces the same and health-care staff alike. When security and
effect as stimulation of the PARASYMPATHETIC confidentiality are assured, images could be
NERVOUS SYSTEM: i.e. it constricts the pupil of transferred via the Internet and teleradiology. In
the eye, stimulates the gut, increases the secre- future, hospitals might be able to eliminate the
tion of saliva, stimulates the bladder, and costly physical transfer and storage of X-ray
increases the irritability of voluntary muscle. In films. The integration of PACS with hospital
poisonous doses it brings on a general paralysis. information systems in the NHS will (hope-
fully) facilitate the introduction of electronic
Uses It is used in medicine in the form of eye radiology.
drops or ointment to treat GLAUCOMA.
Pigeon Breast
Phytomenadione See CHEST, DEFORMITIES OF.
The British Pharmacopoeia name for vitamin K.
(See APPENDIX 5: VITAMINS.) Pigment
The term applied to the colouring matter of
Pia Mater various secretions, blood, etc.; also to any medi-
The membrane closely investing the BRAIN and cinal preparation of thick consistency intended
SPINAL CORD, in which run blood vessels for the for painting on the skin or mucous membranes.
nourishment of these organs.
Piles
Pica See HAEMORRHOIDS.
This is the Latin for magpie and is used to
describe an abnormal craving for unusual foods. Pills
It is not uncommon in pregnancy. Among the Small round masses containing active drugs
unusual substances for which pregnant women held together by syrup, gum, glycerin, or
have developed a craving are soap, clay pipes, adhesive vegetable extracts. They are sometimes
bed linen, charcoal, ashes and almost every without coating, being merely rolled in French
imaginable food stuff taken in excess. In primi- chalk, but often they are covered with sugar or
tive races, the presence of pica is taken as an gelatin. Many people use the term interchange-
indication that the growing fetus requires such ably with tablets, and the pill has come to rep-
food. It is also not uncommon in children in resent oral contraceptives.
P whom, previously, it was an important cause of
LEAD POISONING due to ingestion of paint Pilocarpine
flakes. (See also APPETITE.) An alkaloid (see ALKALOIDS) derived from the
leaves of Pilocarpus microphyllus (jaborandi). It
Picorna Viruses produces the same effects as stimulation of the
These infectious agents derive their name from PARASYMPATHETIC NERVOUS SYSTEM: i.e. it has
pico (small) and from RNA (because they con- exactly the opposite effect to ATROPINE, but
tain ribonuleic acid). They are a group of vir- cannot be used in the treatment of atropine
uses which includes the ENTEROVIRUSES and poisoning as it does not antagonise the action
the RHINOVIRUSES. of poisonous doses of atropine on the brain. Its
main use today is in the form of eye drops to
Picric Acid decrease the pressure inside the eyeball in
A yellow crystalline solid substance which is GLAUCOMA.
used as a fixative for tissues being prepared for
examination under a microscope; it is also used Pilonoidal Sinus
as a dye. A SINUS that contains hairs, usually occurring
in the cleft between the buttocks. It may get
Picture Archiving and infected and cause considerable pain. Treat-
Communications System (PACS) ment is by antibiotics and, if necessary, surgical
The use of digital imaging systems to replace removal.
conventional X-ray pictures and other imaging
techniques. Though expensive to operate, Pimples
digital imaging and storage systems offer prom- Technically known as papules, these are small,
ising possibilities for transmission of clinical raised and inflamed areas on the SKIN. On the
 Pituitary Gland 557

face, the most common cause is ACNE. BOILS Pinworm

(FURUNCULOSIS) start as hard pimples. The See ENTEROBIASIS.
eruption of SMALLPOX and that of CHICKENPOX
begin also with pimples. (See also SKIN, DISEASES Piperacillin
OF.) A ureidopenicillin with a broad spectrum of
antibacterial activity. The drug is active against
Pineal Gland the serious infective agent Pseudomonas aerugi-
A small reddish structure, 10 mm in length and nosa. (See PENICILLIN.)
shaped somewhat like a pine cone (hence its
name), situated on the upper part of the mid- Piperazine
brain (see BRAIN). Many theories have been A drug used for the treatment of threadworms
expounded as to its function, but there is (see ENTEROBIASIS) and ASCARIASIS.
increasing evidence that, in some animals at
least, it is affected by light and plays a part in Pipothiazine
hibernation and in controlling sexual activity An antipsychotic drug for maintenance treat-
and the colour of the skin. This it seems to do ment of SCHIZOPHRENIA. It is given as a depot
by means of a substance it produces known as injection that lasts four weeks. (See NEUROLEP-
MELATONIN. There is also growing evidence TICS; MENTAL ILLNESS.)
that it may play a part in controlling the cir-
cadian rhythms of the body the natural vari- Piroxicam
ations in physiological activities throughout the An intermediate risk, oral non-steroidal anti-
24-hour day. inflammatory drug (see NON-STEROIDAL ANTI-
INFLAMMATORY DRUGS (NSAIDS)) with
Pinna prolonged action. Used to treat pain and in-
The part of the EAR, formed of cartilage and flammation in RHEUMATOID ARTHRITIS, other
skin, that is external to the head. In animals it is musculoskeletal disorders, and acute GOUT.
an important element in detecting the direction
of sound. Pituitary Gland
Also known as the pituitary body and the hy-
Pins and Needles pophysis, this is an ovoid structure, weighing
A form of PARAESTHESIA, or disturbed sensa- around 05 gram in the adult. It is attached to
tion, such as may occur, for example, in NEUR- the base of the BRAIN, and lies in the depression
ITIS or POLYNEURITIS. in the base of the skull known as the sella
turcica. The anterior part is called the adenohy-
Pint pophysis and the posterior part the neurohy- P
A measure of quantity containing 16 fluid pophysis. The gland is connected to the
ounces (wine measure) or 20 fluid ounces HYPOTHALAMUS of the brain by a stalk known
(Imperial measure). The metric equivalent is as the hypophyseal or pituitary stalk.
568 millilitres. (See APPENDIX 6: MEASURE- The pituitary gland is the most important
MENTS IN MEDICINE.) ductless, or endocrine, gland in the body. (See

Vertical cross-section of brain seen from the left showing positions of pineal and pituitary glands.
 558 Pituitary-Linked Disorders

ENDOCRINE GLANDS.) It exerts overall control tumour occurs in childhood, growth hormone
of the endocrine system through the media of a will be suppressed and growth will slow. Gon-
series of hormones which it produces. The adotrophin hormone suppression will prevent
adenohypophysis produces trophic hormones the development of puberty and, if the tumour
(that is, they work by stimulating or inhibiting occurs after puberty, will result in amenorrhoea
other endocrine glands) and have therefore in the female and lack of LIBIDO in both sexes.
been given names ending with trophic or The thyroid-stimulating hormone cells are the
trophin. The thyrotrophic hormone, or next to suffer and the pressure effects on these
thyroid-stimulating hormone (TSH), exerts a cells will result in hypothyroidism (see under
powerful influence over the activity of the THY- THYROID GLAND, DISEASES OF).
ROID GLAND. The ADRENOCORTICOTROPHIC Fortunately the ACTH-producing cells are
HORMONE (ACTH) stimulates the cortex of the the most resistant to extrinsic pressure and this
adrenal glands. GROWTH HORMONE, also is teleologically sound as ACTH is the one pitu-
known as somatotrophin (SMH), controls the itary hormone that is essential to life. However,
growth of the body. There are also two gonado- these cells can suffer damage from intracellular
trophic hormones which play a vital part in the tumours, and adrenocortical insufficiency is not
control of the gonads: these are the follicle- uncommon.
stimulating hormone (FSH), and the luteinis- Information about these disorders may be
ing hormone (LH) which is also known as the obtained from the Pituitary Foundation.
interstitial-cell-stimulating hormone (ICSH)
see GONADOTROPHINS. The lactogenic hor- Pityriasis
mone, also known as prolactin, mammotrophin A skin disorder typified by a bran-like des-
and luteotrophin, induces lactation. quamation (flaking). There are several varieties
The neurohypophysis produces two hor- including P. alba, rosea, versicolor (fungal
mones. One is oxytocin, which is widely used caused) and rubra (exfoliative dermatitis).
because of its stimulating effect on contraction
of the UTERUS. The other is VASOPRESSIN, or Pityriasis alba is a mild form of chronic
the antidiuretic hormone (ADH), which acts eczema (see DERMATITIS) occurring mainly in
on the renal tubules and the collecting tubules children on the face and in young adults on the
(see KIDNEYS) to increase the amount of water upper arms. It is characterised by round or oval
that they normally absorb. flaky patches which are paler than the surround-
ing skin due to partial loss of MELANIN pig-
Pituitary-Linked Disorders ment. The appearance is more dramatic in
ACROMEGALY or gigantism is the result of the dark-skinned or suntanned subjects. Moisturis-
P overactivity of, or tumour formation of cells in, ing cream often suffices, but 1 per cent HYDRO-
the adenohypophysis which produces GROWTH CORTISONE cream is more effective.
HORMONE (see also PITUITARY GLAND). If this
overactivity occurs after growth has ceased, Pityriasis rosea is a common self-limiting
acromegaly arises, in which there is gross over- eruption seen mainly in young adults. It usually
growth of the ears, nose, jaws, and hands and begins as a solitary red flaky patch (often mis-
feet. DWARFISM may be due to lack of growth diagnosed as ringworm). Within a week this
hormone. herald patch is followed by a profuse sym-
DIABETES INSIPIDUS, a condition character- metrical eruption of smaller rose-pink, flaky,
ised by the passing of a large volume of URINE oval lesions on the trunk and neck but largely
every day, is due to lack of the antidiuretic sparing the limbs and face. Itching is variable.
hormone (see VASOPRESSIN). Enhanced produc- The eruption usually peaks within 3 weeks
tion of the ADRENOCORTICOTROPHIC HOR- and fades away leaving collarettes of scale, dis-
MONE (ACTH) leads to CUSHINGS SYNDROME. appearing within 67 weeks. It rarely recurs and
Excessive production of PROLACTIN by micro or a viral cause is suspected but not proved. It is
macro adenomas (benign tumours) leads to not contagious and there is no specific treat-
hyperprolactinaemia and consequent AMENOR- ment, but crotamiton cream (Eurax) may relieve
RHOEA and GALACTORRHOEA. Some adenomas discomfort.
do not produce any hormone but cause effects
by damaging the pituitary cells and inhibiting PKU
their hormone production. See PHENYLKETONURIA.
The most sensitive cells to extrinsic pressure
are the gonadotrophin-producing cells and the Placebo
growth-hormone producing cells, so that if the Placebo is the Latin for I will please and
 Plague 559

implies giving an inactive treatment. Tradition- third stage of labour (see PREGNANCY AND
ally, placebos were used to pacify without actu- LABOUR).
ally benefiting the patient. They were inactive,
often highly coloured, substances formerly Placenta Praevia
given to please or gratify the patient but with- Implantation of the PLACENTA in the bottom
out pharmacological benefit. Nowadays they part of the UTERUS adjacent to or over the CER-
are used in controlled studies, approved by ETH- VIX. The condition may cause few problems
ICS COMMITTEES and with patient consent, to during pregnancy or labour; it may, however,
determine the efficacy of drugs. cause vaginal bleeding late in pregnancy or hin-
However, pharmacologically inert com- der vaginal delivery of the baby and this may
pounds can relieve symptoms, and this is called necessitate obstetric intervention.
the placebo effect. The reassurance that is
associated with placebo administration is Placentography
accompanied by measurable changes in body The procedure of rendering the PLACENTA
function which are affected through auto- visible by means of X-rays. This can be done
nomic pathways and humoral mechanisms. either by using what is known as soft-tissue
Alterations in blood pressure and pulse fre- radiography, or by injecting a radio-opaque
quency are especially common. Placebos have substance into the bloodstream or into the
the ability to relieve a variety of symptoms in a amniotic cavity (see AMNION). The procedure
consistent proportion of the population in has some risk to both mother and fetus, and is
some studies in as many as 30 per cent. Some carried out under expert supervision. It can
patients with symptoms such as pain or cough help to assess the cause of antepartum haemor-
will respond to placebo medications, and an rhage. The placenta and fetus can now be visu-
even higher proportion of patients with alised by the non-invasive and safe method of
psychological symptoms such as anxiety or ULTRASOUND.
insomnia may benefit. In judging the
effectiveness of a drug, the comparison must Plague
be with a placebo rather than with no treat- This infection also known as bubonic plague
ment at all. is caused by the bacterium Yersinis pestis.
Plague remains a major infection in many trop-
Placenta ical countries.
The thick, spongy, disc-like mass of tissue The reservoir for the bacillus in urban infec-
which connects the EMBRYO with the inner sur- tion lies in the black rat (Rattus rattus), and less
face of the UTERUS, the embryo otherwise lying importantly the brown (sewer) rat (Rattus nor-
free in the amniotic fluid (see AMNION). The vegicus). It is conveyed to humans by the rat P
placenta is mainly a new structure growing with flea, usually Xenopsylla cheopis: Y. pestis multi-
the embryo, but, when it separates, a portion of plies in the gastrointestinal tract of the flea,
the inner surface of the womb called the which may remain infectious for up to six
maternal placenta comes away with it. It is weeks. In the pneumonic form (see below),
mainly composed of loops of veins belonging to human-to-human transmission can occur by
the embryo, lying in blood-sinuses, in which droplet infection. Many lower mammals (apart
circulates maternal blood. Thus, although no from the rat) can also act as a reservoir in syl-
mixing of the blood of embryo and mother vatic transmission which remains a major prob-
takes place, there is ample opportunity for the lem in the US (mostly in the south-western
exchange of fluids, gases, and the nutrients States); ground-squirrels, rock-squirrels, prairie
brought by the mothers blood. The width of dogs, bobcats, chipmunks, etc. can be affected.
the full-sized placenta is about 20 cm (8 Clinically, symptoms usually begin 28 days
inches), its thickness 25 cm (1 inch). One sur- after infection; disease begins with fever, head-
face is rough and studded with villi, which con- ache, lassitude, and aching limbs. In over two-
sist of the loops of fetal veins; the other is thirds of patients, enlarged glands (buboes)
smooth, and has implanted in its centre the appear usually in the groin, but also in the
umbilical cord, or navel string, which is about axillae and cervical neck; this constitutes
as thick as a finger and 50 cm (20 inches) long. bubonic plague. Haemorrhages may be present
It contains two arteries and a vein, enters the beneath the skin causing gangrenous patches
fetus at the navel, and forms the sole connec- and occasionally ulcers; these lesions led to the
tion between the bodies of mother and fetus. epithet Black Death. In a favourable case, fever
The name afterbirth is given to the structure abates after about a week, and the buboes dis-
because it is expelled from the womb in the charge foul-smelling pus. In a rapidly fatal form
 560 Plantar

(septicaemic plague), haematogenous transmis- the material which produces clotting (see
sion produces mortality in a high percentage of COAGULATION). When the plasma is clotted,
cases. Pneumonic plague is associated with the thinner fluid separating from the clot is the
pneumonic consolidation (person-to-person serum.
transmission) and death often ensues on the
fourth or fifth day. (The nursery rhyme Ring- Plasma Cells
o-ring o roses, a pocketful o posies, atishoo! These are cells that produce ANTIBODIES and
atishoo!, we all fall down is considered to have occur in bone-forming tissue as well as the lin-
originated in the 17th century and refers to this ing of the gastrointestinal tract and the lungs.
form of the disease.) In addition, meningitic The cells develop in LYMPH NODES, SPLEEN and
and pharyngeal forms of the disease can occur; BONE MARROW when T-lymphocytes (see
these are unusual. Diagnosis consists of demon- IMMUNITY) are stimulated by antigens (see
stration of the causative organism. ANTIGEN) to produce the precursor cells from
Treatment is with tetracycline or doxycy- which plasma cells originate.
cline; a range of other antibiotics is also effect-
ive. Plague remains (together with CHOLERA Plasma Exchange
and YELLOW FEVER) a quarantinable disease. Also known as plasmapheresis. The removal of
Contacts should be disinfected with insecticide the circulating PLASMA from the patient. It is
powder; clothes, skins, soft merchandise, etc. done by removing blood from a patient and
which have been in contact with the infection returning the red cells with a plasma expander.
can remain infectious for several months; sus- The plasma exchange is carried out through an
pect items should be destroyed or disinfected in-dwelling CANNULA in the femoral vein, and
with an insecticide. Ships must be carefully the red cells and plasma are separated by a
checked for presence of rats; the rationale of hemonetics separator. Usually a sequence of
anchoring a distance from the quay prevents three or four sessions is undertaken, at each of
access of vermin. (See also EPIDEMIC; PANDEMIC; which 23 litres of plasma are removed. The
NOTIFIABLE DISEASES.) lost plasma can either be replaced by human
serum albumin (see ALBUMINS) or a plasma
Plantar expander.
Describing anything related to the sole of the In autoimmune disorders, disease is due to
foot. damage wrought by circulating ANTIBODIES or
sensitised lymphocytes (see LYMPHOCYTE). If the
Plantar Dermatosis disease is due to circulating humoral antibodies,
A common form of eczema (see DERMATITIS) of removal of these antibodies from the body
P the soles of the feet typically seen in boys with should theoretically relieve the disorder. This is
an atopic (see ATOPY) background who con- the principle on which plasma exchange was
stantly wear trainers. used in the management of autoimmune
diseases due to circulating antibodies. Such
Plantar Fasciitis disorders include Goodpastures syndrome,
See FASCIITIS. SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) and
MYASTHENIA GRAVIS. One of the problems in
Plaque the use of plasma exchange in the treatment of
(1) A coating of the TEETH which forms as a such diseases is that the body responds to the
result of poor mouth and dental hygiene. It removal of an antibody from the circulation by
consists of food debris and bacteria; later, cal- enhanced production of that antibody by the
cium salts will be deposited in it to form calcu- immune system. It is therefore necessary to
lus. It is therefore associated with both caries suppress this homeostatic response with cyto-
and periodontal disease (see TEETH, DISORDERS toxic drugs such as AZATHIOPRINE. Neverthe-
OF Caries of the teeth). less, remissions can be achieved in autoimmune
(2) Raised patch on the skin resulting from the diseases due to circulating antibodies by the
merging or enlargement of papules (see PAPULE; process of plasma exchange.
PIMPLES).
Plasmapheresis
Plasma See PLASMA EXCHANGE.
The name applied to the straw-coloured fluid
portion of the BLOOD composed of a solution Plasma Transfusion
of various inorganic salts of sodium, potassium, This procedure is sometimes used instead of
calcium, etc., as well as SERUM and fibrinogen, blood TRANSFUSION. PLASMA the fluid part of
 Pleurisy 561

blood from which the cells have been separated Plethora

may be dried and in powder form kept almost A condition of fullness of the blood vessels in a
indefinitely; when wanted it is reconstituted by particular part or in the whole body. This
adding sterile distilled water. In powder form it results in a florid, red appearance of the affected
can be transported easily and over long dis- area, particularly the face. The volume of blood
tances. Transfusion of plasma is especially use- may be increased (POLYCYTHAEMIA) or the
ful in the treatment of SHOCK. One advantage blood vessels beneath the skin may be dilated.
of plasma transfusion is that it is not necessary Plethoric lung fields are seen on X-rays of
to carry out testing of blood groups before patients with left-to-right shunts through the
using it. heart wall (see SEPTAL DEFECT).

Plasmids Plethysmograph
A generic description of any discrete agents in An apparatus for estimating changes in the size
cells that have genetic functions. They include of any part placed in the apparatus; in this way
plasmagenes (self-reproducing copies of a changes in the volume of blood in a part can be
nuclear gene existing outside the cell nucleus) measured.
and viruses.
Pleura
Plasmin The name of the membrane which, on either
Also called fibrinolysin, this is an ENZYME that side of the chest, forms a covering for one lung.
digests the protein FIBRIN. It dissolves blood The two pleurae are distinct, though they touch
clots (see COAGULATION) and so is present in the one another for a short distance behind the
blood in the form of PLASMINOGEN, an inactive breast-bone. (See LUNGS.)
precursor.
Pleural Cavity
Plasminogen The normally restricted space between the par-
A precursor of PLASMIN, an ENZYME that digests ietal and the visceral PLEURA, which slide over
the protein FIBRIN the main constituent of one another as the individual breathes in and
blood clots (see COAGULATION). When tissue is out. If gas or fluid are introduced as a result of
damaged, activators are released which provoke injury or infection, the pleural surfaces are sep-
the conversion of plasminogen into plasmin. arated and the pleural space increases in vol-
ume. This usually causes breathing difficulties.
Plasmodium
The general term applied to minute proto- Pleurisy
plasmic cells, and particularly to those which Inflammation of the PLEURA or serous mem- P
cause MALARIA and allied diseases. brane investing the lung and lining the inner
surface of the ribs. It is a common condition,
Plaster of Paris and may be either acute or chronic, the latter
A form of calcium sulphate, which, after soak- being usually tuberculous in origin (see
ing in water, sets firmly. For this reason it is TUBERCULOSIS).
widely used as a form of splinting in the treat- Many cases of pleurisy are associated with
ment of fractures, for producing casts to only a little effusion, the inflammation consist-
immobilise parts of the body, and for dental ing chiefly in exudation of FIBRIN: to this form
models. Splints are made with bandages the term dry pleurisy is applied. Further,
impregnated with plaster and a suitable pleurisy may be limited to a very small area or,
adhesive. Its great advantage, compared with an on the contrary, may affect, throughout a
ordinary splint, is that it can be moulded to the greater or less extent, the pleural surfaces of
shape of the limb. both lungs.

Plastic Surgery Causes Pleurisy is often associated with other

See RECONSTRUCTIVE (PLASTIC) SURGERY. forms of inflammatory disease within the
chest, more particularly PNEUMONIA, BRON-
Platelets CHIECTASIS, and tuberculosis; it occasionally
Blood platelets, or thrombocytes, are small accompanies PERICARDITIS. It may also be due
spherical bodies in the BLOOD, which play an to carcinoma of the lung, or be secondary to
important part in the process of its COAGULA- abdominal infections such as subphrenic
TION. Normally, there are around 300,000 per abscess. Further, wounds or injuries of the
cubic millimetre of blood. thoracic walls are apt to set up pleurisy.
 562 Pleurodynia

Symptoms The symptoms of pleurisy vary, Pneumoconiosis

being generally well marked, but sometimes The general name applied to a chronic form of
obscure. inflammation of the LUNGS which is liable to
DRY PLEURISY In the case of dry pleurisy, which affect people who constantly inhale irritating
is, on the whole, the milder form, the chief particles at work. It has been defined by the
symptom is a sharp pain in the side, felt espe- Industrial Injuries Advisory Council as: Per-
cially on breathing. Fever may or may not be manent alteration of lung structure due to the
present. There is a slight, dry cough, and inhalation of mineral dust and the tissue reac-
breathing is quicker than normal and shallow. tions of the lung to its presence, but does not
PLEURISY WITH EFFUSION is usually more include bronchitis and emphysema. Some of
severe than dry pleurisy, and, although it may in the tradespeople liable to suffer are stone-
some cases develop insidiously, it is in general masons, potters, steel-grinders, coal-miners,
ushered in sharply by shivering and fever, like millers, and workers in cotton, flax, or wool
other acute inflammatory diseases. Pain is felt in mills. (See also OCCUPATIONAL HEALTH, MEDI-
the side or breast, of a severe cutting or stabbing CINE AND DISEASES; TUBERCULOSIS.)
character. A dry cough usually occurs and
breathing is painful and difficult. Pneumocystis Pneumonia
PNEUMONIA caused by a species of the genus of
Treatment The treatment varies greatly with PROTOZOA, a parasitic micro-organism. Pneu-
the form and severity of the attack. Bed rest, mocystis carinii causes an opportunistic infection
antibiotics, analgesics and antipyretics are in the lung which is dangerous to people whose
advisable. A large pleural effusion may need to immune system is impaired (see IMMUNITY),
be drained via an aspiration needle. thus reducing their resistance to infections.
People with AIDS/HIV or LEUKAEMIA have
Pleurodynia impaired immune systems and P. carinii is a
Also known as BORNHOLM DISEASE. A painful major cause of death in the former. Fever, dry
condition of the chest wall, it is usually the cough and breathlessness are among the symp-
result of an infection of coxsackie virus B (see toms; treatment is with high doses of antibiotic
COXSACKIE VIRUSES) and may occur in epi- drugs such as CO-TRIMOXAZOLE or
demics (see EPIDEMIC). Fever, sore throat, PENTAMIDINE.
headache and malaise are typical but the con-
dition is self-limiting, subsiding within a few Pneumonectomy
days. The operation of removing an entire lung (see
LUNGS) in such diseases as BRONCHIECTASIS,
P Plexus TUBERCULOSIS, and cancer of the lung.
A network of nerves or vessels: for example, the
brachial and sacral plexuses of nerves and the Pneumonia
choroid plexus of veins within the brain. Pneumonia is an inflammation of the lung tis-
sue (see LUNGS) caused by infection. It can occur
Plumbism without underlying lung or general disease, or
Another name for LEAD POISONING. in patients with an underlying condition that
makes them susceptible.
Plummer-Vinson Syndrome Pneumonia with no predisposing cause
Hypochromic ANAEMIA and difficulty in swal- community-acquired pneumonia is caused
lowing due to an oesophageal web. most often by Streptococcus pneumoniae
(PNEUMOCOCCUS). The other most common
Pneumo- causes are viruses, Mycoplasma pneumoniae and
A prefix relating to the LUNGS or to air. Legionella species (Legionnaires disease).
Examples are PNEUMONIA, PNEUMONECTOMY Another cause, Chlamydia psittaci, may be
and PNEUMOPERITONEUM. associated with exposure to perching birds.
In patients with underlying lung disease,
Pneumococcus such as CHRONIC OBSTRUCTIVE PULMONARY
A type of streptococcal bacterium (see DISEASE (COPD) or BRONCHIECTASIS as in CYS-
STREPTOCOCCUS) which can cause otitis media TIC FIBROSIS, other organisms such as Haemo-
(see EAR, DISEASES OF Diseases of the middle philus influenzae, Klebsiella, Escherichia coli
ear), TONSILLITIS, PNEUMONIA, MENINGITIS and Pseudomonas aeruginosa are more promin-
and SEPTICAEMIA. It is usually sensitive to ent. In patients in hospital with severe under-
PENICILLIN. lying disease, pneumonia, often caused by
 Podophyllin 563

gram-negative bacteria (see GRAMS STAIN), is may be needed as judged by the oxygen satur-
commonly the terminal event. ation or blood gas measurement.
In patients with an immune system sup- Possible complications of pneumonia are
pressed by pregnancy and labour, infection with local changes such as lung abscess, pleural effu-
HIV, CHEMOTHERAPY or immunosuppressive sion or EMPYEMA and general problems such as
drugs after organ transplantation, a wider range cardiovascular collapse and abnormalities of
of opportunistic organisms needs to be con- kidney or liver function. Appropriate treatment
sidered. Some of these organisms such as should result in complete resolution of the lung
CYTOMEGALOVIRUS (CMV) or the fungus Pneu- changes but some FIBROSIS in the lung may
mocystis carinii rarely cause disease in immuno- remain. Pneumonia can be a severe illness in
competent individuals those whose bodys previously fit people and it may take some
immune (defence) system is effective. months to return to full fitness.
TUBERCULOSIS is another cause of pneu-
monia, although the pattern of lung involve- Pneumonitis
ment and the more chronic course usually An inflammation of the lung (see LUNGS) due to
differentiate it from other causes of pneumonia. chemical or physical agents.

Symptoms The common symptoms of Pneumoperitoneum

pneumonia are cough, fever (sometimes with A collection of air in the peritoneal cavity (see
RIGOR), pleuritic chest pain (see PLEURISY) and PERITONEUM). Air introduced into the periton-
shortness of breath. SPUTUM may not be pres- eal cavity collects under the diaphragm which is
ent at first but later may be purulent or reddish thus raised and collapses the lungs. This pro-
(rusty). cedure was sometimes carried out in the
Examination of the chest may show the typ- treatment of pulmonary tuberculosis in the pre-
ical signs of consolidation of an area of lung. antibiotic days as an alternative to artificial
The solid lung in which the alveoli are filled PNEUMOTHORAX.
with inflammatory exudate is dull to percussion
but transmits sounds better than air-containing Pneumothorax
lung, giving rise to the signs of bronchial A collection of air in the pleural cavity, into
breathing and increased conduction of voice which it has gained entrance by a defect in the
sounds to the stethoscope or palpating hand. lung or a wound in the chest wall. When air
The chest X-ray in pneumonia shows opaci- enters the chest, the lung immediately collapses
ties corresponding to the consolidated lung. towards the centre of the chest; but, air being
This may have a lobar distribution fitting with absorbed from the pleural cavity, the lung
limitation to one area of the lung, or have a less expands again within a short time. (See LUNGS, P
confluent scattered distribution in broncho- DISEASES OF.)
pneumonia. Blood tests usually show a raised Tension pneumothorax is a life-threatening
white cell (LEUCOCYTES) count. The organism condition in which the air in the hemithorax is
responsible for the pneumonia can often be under such pressure that it forces the heart to
identified from culture of the sputum or the the other side and compresses the still-inflated
blood, or from blood tests for the specific lung on the other side. It must be promptly
ANTIBODIES produced in response to the relieved by inserting a hollow tube into the
infection. pleural cavity a chest drain.
Artificial pneumothorax was an operation
Treatment The treatment of pneumonia often performed in the pre-antibiotic days to
involves appropriate antibiotics together with treat pulmonary tuberculosis. Air was run into
oxygen, pain relief and management of any the pleural cavity to cause collapse of one lung,
complications that may arise. When treatment which rested it and allowed cavities in it to heal.
is started, the causative organism has often not
been identified so that the antibiotic choice is Podagra
made on the basis of the clinical features, preva- Another name for GOUT affecting the foot.
lent organisms and their sensitivities. In severe
cases of community-acquired pneumonia (see Podophyllin
above), this will often be a PENICILLIN or one of A resin derived from podophyllum plants, its
the CEPHALOSPORINS to cover Strep. pneumo- active agent, podophyllotoxin, in alcoholic
niae together with a macrolide such as ERYTH- solution is used to treat genital WARTS. Paints,
ROMYCIN. Pleuritic pain will need analgesia to creams and impregnated plasters are used for
allow deep breathing and coughing; oxygen calluses and warts elsewhere.
 564 Poikilocytosis

Poikilocytosis BON MONOXIDE (CO) is by far the most com-

This is a term used to describe the variation mon cause of death due to poisoning. The most
seen in the shape of red blood cells in some common agents involved in intentional or acci-
disorders of the BONE MARROW. dental poisoning are drugs, particularly
ANALGESICS, ANTIDEPRESSANT DRUGS and
Poisons SEDATIVES. Alcohol is also commonly taken by
A poison is any substance which, if absorbed by, adults, usually in combination with drugs.
introduced into or applied to a living organism, Children frequently swallow household
may cause illness or death. The term toxin is cleaners, white spirit, plant material such as
often used to refer to a poison of biological ori- belladonna (deadly nightshade) and certain
gin. Toxins are therefore a subgroup of poisons, mushrooms; for example, death cap and fly
but often little distinction is made between the agaric aftershave and perfume as well as drugs.
terms. The study of the effects of poisons is If possible, the suspect container, drug or plant
toxicology and the effects of toxins, toxinology. should be taken with the victim to the hospital
The concept of the dose-response is import- or doctor. The use of child-resistant containers
ant for understanding the risk of exposure to a has reduced the number of admissions of chil-
particular substance. This is embodied in a dren to hospital for treatment. Bixtrex is an
statement by Paracelsus (c.14931541): All intensely bitter-tasting agent which is often
substances are poisons; there is none which is added to products to discourage ingestion;
not a poison. The right dose differentiates a however, not everybody is able to taste it, nor
poison and a remedy. has any beneficial effect been proven.
Poisoning may occur in a variety of ways:
deliberate SUICIDE, substance abuse or mur- Treatment of poisoning usually begins with
der; accidental including accidental overdose decontamination procedures. For ingested sub-
of medicines; occupational; and environmental stances this may involve making the patient sick
including exposure during fire. or washing the stomach out (GASTRIC LAVAGE):
Ingestion is the most common route of this is usually only worthwhile if performed
exposure, but poisoning may also occur soon after ingestion. It should be emphasised
through inhalation, absorption through the that salt (sodium chloride) water must never be
skin, by injection and through bites and stings given to induce vomiting, since this procedure
of venomous animals. Poisoning may be is dangerous and has caused death. For sub-
described as acute, where a single exposure pro- stances spilt on the skin, the affected area
duces clinical effects with a relatively rapid should immediately be thoroughly washed and
onset; or chronic, where prolonged or repeated all contaminated clothing removed. Following
P exposures may produce clinical effects which eye exposure, the affected eye/s should be
may be insidious in onset, cumulative and in thoroughly irrigated with saline or water.
some cases permanent. Treatment thereafter is generally symptom-
Diagnosis of poisoning is usually by circum- atic and supportive, with maintenance of the
stantial evidence or elimination of other causes victims respiratory, neurological and cardio-
of the clinical condition of the patient. Some vascular systems and, where appropriate, moni-
substances (e.g. opioids) produce a character- toring of their fluid and electrolyte balance and
istic clinical picture in overdose that can help hepatic and renal function. There are specific
with diagnosis. In some patients laboratory antidotes for a few substances: the most
analysis of body fluids or the substance taken important of these are PARACETAMOL, iron,
may be useful to determine or confirm the cyanide (see CYANIDE POISONING), opioids (see
offending agent. Routine assays are not neces- OPIOID), DIGOXIN, insecticides and some heavy
sary. For a very small number of poisons, such metals. Heavy-metal poisoning is treated with
as paracetamol, aspirin, iron and lead, the man- CHELATING AGENTS chemical compounds
agement of the patient may depend on measur- that form complexes by binding metal ions:
ing the amount of poison in the bloodstream. desferrioxamine and pencillinamine are two
Accurate statistics on the incidence of such agents. The number of people presenting
poisoning in the UK are lacking. Mortality with paracetamol overdose a common drug
figures are more reliable than morbidity stat- used for attempted suicide has fallen sharply
istics; annually, well over 100,000 cases of poi- since restrictions were placed on its over-the-
soning are admitted to hospital. The annual counter sales.
number of deaths from poisoning is relatively When a patient presents with an illness
small about 300 and in most cases patients thought to be caused by exposure to substances
die before reaching hospital. Currently, CAR- at work, further exposure should be limited or
 Polyarteritis Nodosa 565

prevented and investigations undertaken to the spinal cord, especially those in the lumbar
determine the source and extent of the prob- region; the grey matter of the brain stem and
lem. Acutely poisoned workers will usually go cortex may also be damaged.
to hospital, but those suffering from chronic Vaccination is given to infants at two, three
exposure may attend their GP with non-specific and four months: a booster dose is given at
symptoms (see OCCUPATIONAL HEALTH, MEDI- around the age of five. The vaccine contains all
CINE AND DISEASES). three types of polio virus. Two types of vaccine
In recent years, legislation has been enacted are available: inactivated polio virus (IPV) con-
in the UK to improve safety in the workplace tains dead virus and is administered by injec-
and to ensure that data on the hazardous con- tions; oral polio vaccine (OPV) contains live,
stituents and effects of chemicals are more read- harmless strains. The latter is used in the
ily available. These official controls include the United Kingdom.
Control of Substances Hazardous to Health
(COSHH) and the Chemicals (Hazard Infor- Symptoms The incubation period is around
mation and Packaging) Regulations (CHIP) 714 days, the onset being marked by a mild
and are UK legislation in response to European fever and headache which improves after a few
Union directives. days. In around 85 per cent of infected children
The National Poisons Information Service is there is no further progression, but in some
a 24-hour emergency telephone service avail- after approximately one week the symptoms
able to the medical profession and provides recur, together with neck stiffness and signs of
information on the likely effects of numerous meningeal irritation (see MENINGES). Weakness
agents and advice on the management of the of individual muscle groups is common, and
poisoned patient. The telephone numbers are may progress to a variable extent, depending
available in the medical literature. In the UK on the distribution of the virus to widespread
this is not a public-access service. People who PARALYSIS. Involvement of the diaphragm and
believe they, or their relatives, have been intercostal muscles may lead to respiratory fail-
poisoned should seek medical advice from ure and rapid death unless artificial respiration
their GPs or attend their local hospital. is provided. Involvement of the cranial nerves
and brain may lead to nystagmus (see under EYE,
Toxbase The National Poisons Information DISORDERS OF), hoarseness and difficulty in
Service provides a primary clinical toxicology swallowing, and CONVULSIONS may occur in
database on the Internet: www.spib.axl.co.uk. young children. The CEREBROSPINAL FLUID
This website provides information about rou- shows an early increase in lymphocytes, fol-
tine diagnosis, treatment and management of lowed by a rise in protein concentration.
people exposed to drugs, household products P
and industrial and agricultural products. Treatment There is no effective drug treat-
(See also APPENDIX 1: BASIC FIRST AID.) ment for the infection. Treatment involves early
bed rest, followed by PHYSIOTHERAPY and
Poliomyelitis orthopaedic measures as required. At the onset
Once known as infantile paralysis, this disease is of respiratory difficulties a TRACHEOSTOMY and
caused by a viral infection involving the BRAIN artificial ventilation should be started. (In the
and SPINAL CORD. Since the development of 1950s, when polio epidemics were occurring,
effective vaccines in the 1950s (see IMMUNISA- respiratory difficulties were treated by placing
TION), polio has been practically eliminated in patients in an iron lung a large, airtight,
most developed countries. People who have not cylindrical container in which the air pressure
been fully vaccinated, however, may get the dis- was raised and lowered to simulate normal
ease: it remains a serious risk for unvaccinated breathing.) In cases of severe paralysis with per-
travellers to Africa, Asia or southern Europe. sistent wasting of the limbs, surgery may be
Most reported cases are now from sub-Saharan necessary to minimise the resulting disability.
Africa.
Pollex
Pathology There are three types of virus, A Latin term for thumb.
infection spreading by the stools-contaminated
hands-mouth route. Children are most Polyarteritis Nodosa
susceptible. Also known as periarteritis nodosa. A rare but
One attack usually produces permanent potentially serious disease, probably caused by a
immunity, and second attacks are rare. The disturbance of the immune system (see IMMUN-
virus typically affects the anterior horn cells of ITY). Prolonged fever and obscure symptoms
 566 Polyarthritis

referable to any system of the body are associ- Polycythaemia

ated with local areas of inflammation along the A rise in the amount of HAEMOGLOBIN in the
arteries, giving rise to nodules in their walls. blood. This may be caused by an excess in
Large doses of CORTICOSTEROIDS, coupled the number of ERYTHROCYTES produced in the
with IMMUNOSUPPRESSANT treatment, usually BONE MARROW or to a fall in the total volume
curtail the disorder. Recovery occurs in about of PLASMA in the circulatory system. It may also
50 per cent of cases. be a response to reduced oxygen levels for
example, among people living at high altitudes
Polyarthritis or to liver or kidney disease: this type is called
A rheumatic disorder usually caused by secondary polycythaemia.
RHEUMATOID ARTHRITIS that affects several The disorder may, however, occur for no
joints in the body. The joints are stiff, painful obvious reason and is then called polycythaemia
and swollen. Different joints may be affected at vera. This type develops mainly in people over
the same time or in various sequences. 40 and about 400 people develop the disorder
every year in the United Kingdom. The blood
Polychromasia thickens, the sufferer may develop high blood
Also polychromatophilia; terms applied to pressure, flushing, headaches, itching and an
an abnormal reaction of the red blood cells in enlarged spleen. A stroke may occur later in the
severe ANAEMIA. They have a bluish tinge disease process. Treatment of polycythaemia
instead of the normal red colour in a blood film vera is by regular removal of blood by VENE-
stained by the usual method. It is a sign that the SECTION, sometimes in combination with an
cell is not fully developed. anticancer drug. Secondary polycythaemia is
treated by remedying the underlying cause.
Polychromatophilia Polycythaemia rubra vera A disorder in
See POLYCHROMASIA.
which the red blood cells increase in number
along with an increase in the number of white
Polycystic Disease of the Kidney blood cells and platelets. The cause is unknown.
An inherited disease in which the KIDNEYS con- Severe cases may require treatment with CYTO-
tain many cysts. These grow in size until nor- TOXIC drugs or RADIOTHERAPY.
mal kidney tissue is largely destroyed. Cysts
may also occur in other organs such as the liver. Polydactyly
In adults, the disease will cause HYPERTENSION The presence of extra, or supernumerary, fin-
and kidney failure. There is also a juvenile gers or toes.
form. There is no effective treatment, although
P symptoms can be alleviated by DIALYSIS Polydipsia
and sometimes kidney transplant (see Excessive thirst, which is a symptom of DIA-
TRANSPLANTATION). BETES MELLITUS and some other diseases.

Polycystic Ovary Syndrome Polyenes

Characterised by scanty (or absent) MENSTRU- Antifungal agents that include AMPHOTERICIN
ATION, INFERTILITY, hirsutism (excessive hairi- (given by intravenous injection in the treatment
ness) and OBESITY and the sufferers often have of systemic ASPERGILLOSIS) and NYSTATIN,
multiple cysts in their OVARIES. applied topically for fungus infection of the
The condition is caused by an imbalance skin, mouth and other mucous membranes.
between LUTEINISING HORMONE (LH) and
FOLLICLE-STIMULATING HORMONE (FSH); this Polygene
imbalance stops OVULATION and varies the One of several GENES that between them con-
TESTOSTERONE output of the ovaries. The trol a single characteristic in an individual.
treatment may be with CLOMIPHENE; with a With each polygene exerting a slight effect, the
PROGESTOGEN drug; with LUTEINISING genetic outcome is the consequence of group
HORMONE-RELEASING HORMONE (LHRH); or action. The hereditary characteristics produced
with oral contraceptives (see under CONTRACEP- in this way are usually those of a quantitative
TION Non-barrier methods). The treatment type for instance, an individuals height.
chosen depends on the severity of the disease
and whether the woman wants to conceive. Polymorph
Rarely a section of ovarian tissue is surgically (Diminutive of polymorphonuclear leucocyte.)
removed. A name applied to certain white corpuscles of
 Polysaccharide 567

the blood which have a nucleus of irregular and Polypill

varied shape. These form between 70 and 75 A suggestion by two epidemiologists, made in
per cent of all the white corpuscles. (See the British Medical Journal in 2003, that many
BLOOD.) lives could be saved if all persons aged over 55
took a daily combination pill they termed the
Polymyalgia Rheumatica polypill. Its components would be ASPIRIN, a
A form of rheumatism characterised by gross CHOLESTEROL-lowering agent, FOLIC ACID and
early-morning stiffness, which tends to ease off two blood-pressure-lowering agents. The sug-
during the day, and pain in the shoulders and gestion caused a massive correspondence as it
sometimes around the hips. It affects women implied treating a whole population rather than
more than men, and is rare under the age of 60. individuals considered to be at special risk.
The cause is still obscure. It responds well to
PREDNISOLONE, but treatment may need to be Polyposis
long continued. On the other hand the condi- The presence of a crop, or large number, of
tion is not progressive and does not lead to polypi (see POLYPUS). The most important form
disability. of polyposis is that known as familial polyposis
coli. This is a hereditary disease characterised
Polymyositis by the presence of large numbers of polypoid
A connective-tissue disease affecting the tumours in the large bowel. Every child born to
muscles throughout the body. This rare dis- an affected parent stands a fifty-fifty chance of
order, which is associated with DERMATOMY- developing the disease. Its importance is that
OSITIS, may be acute or chronic but it usually sooner or later one or more of these tumours
affects the muscles of the shoulders or hip areas. undergoes cancerous change. If the affected gut
The muscles weaken and are tender to the is removed surgically before this occurs, and
touch. Diffuse inflammatory changes occur and preferably before the age of 20, the results are
symptomatic relief may be obtained with excellent.
CORTICOSTEROIDS.
Polypus
Polymyxin or polyp (plural: polypi). A general name
A group of antibiotics derived from various spe- applied to tumours which are attached by a
cies of Bacillus polymyxa. One variety, colistin, is stalk to the surface from which they spring. The
used to sterilise the bowels before surgery as it is term refers only to the shape of the growth and
not absorbed when given by mouth. The drugs has nothing to do with its structure or nature.
are sometimes used in topical applications for Most polypi are of a simple nature, although
malignant polypi are also found. The usual P
infections of the skin, eye and ear.
structure of a polypus is that of a fine fibrous
core covered with epithelium resembling that of
Polyneuritis the surrounding surface. The sites in which
An inflammatory condition of nerves in various
polypi are most usually found are the interior of
parts of the body. (See NEURITIS.)
the nose, the outer meatus of the ear, and the
interior of the womb, bladder, or bowels (see
Polyp POLYPOSIS).
See POLYPUS. Their removal is generally easy, as they are
simply twisted off, or cut off, by some form of
Polypeptide snare or ligature. (The tissue removed should be
A molecule in which several AMINO ACIDS are checked for malignant cells.) Those which are
joined together by peptide bonds. PROTEIN situated in the interior of the bladder or bowels,
molecules are polypeptides. and whose presence is usually recognised
because blood appears in the urine or stools,
Polypharmacy require a more serious operation usually an
A term applied to the administration of too endoscopic examination (see ENDOSCOPE).
many drugs to one person. Sometimes combin-
ations of drugs are an effective means of treat- Polysaccharide
ment, reducing the risk of drug resistance. A CARBOHYDRATE comprising several mono-
Polypharmacy, however, worsens the risk of saccharides linked in long chains. Polysacchar-
drug interactions and of adverse effects, espe- ides store energy as starch in plants and
cially in the elderly. glycogen in animals and they also form the
 568 Polyuria

structural parts of plants (as cellulose) and ani- 5,000 people in some countries. The British
mals (as mucopolysaccharides). king, George III, suffered from porphyria, a
disorder unrecognised in the 18th century.
Polyuria
The production of excessive amounts of URINE Porphyrins
(1,500 ml or thereabout is the usual daily quan- Complex organic compounds which are sensi-
tity). It is a symptom of DIABETES MELLITUS, tive to light and form the basis of respiratory
DIABETES INSIPIDUS and chronic renal failure. pigments for example, haemoglobin and
myoglobin. Porphyrins are crucial to many
Pompholyx metabolic oxidation/reduction reactions in
See DERMATITIS. animals, plants, and micro-organisms.

Popliteal Space Portal Hypertension

The name given to the region behind the knee. Raised blood pressure in the PORTAL VEIN
The muscles attached to the bones immediately entering the LIVER. This results in increased
above and below the knee bound a diamond- pressure in the veins of the oesophagus and
shaped space through which pass the main upper stomach and these grow in size to form
artery and vein of the limb (known in this part varices dilated tortuous veins. Sometimes
of their course as the popliteal artery and vein); these varices rupture, causing bleeding into the
the tibial and common peroneal nerves (which oesophagus. The raised pressure also causes
continue the sciatic nerve from the thigh down fluid to collect in the abdomen and form
to the leg); the external saphenous vein; and ASCITES. The commonest reason for portal
several small nerves and lymphatic vessels. The hypertension is cirrhosis (fibrosis) of the liver
muscles which bound the upper angle of the (see LIVER, DISEASES OF). THROMBOSIS in the
space and which are attached to the leg bones portal vein may also be a cause. Treatment
by strong prominent tendons are known as requires the cause to be tackled, but bleeding
the hamstrings. The lower angle of the space from ruptured vessels may be stopped by inject-
lies between the two heads of the gastrocnemius ing a sclerosant or hardening solution into and
muscle, which makes up the main bulk of the around the veins. Sometimes a surgical shunt
calf of the leg. may be done to divert blood from the portal
vein to another blood vessel.
Poppy
Two species are used in medicine: Papaver som- Portal System
niferum, the white opium-poppy (see OPIUM), A vein or collection of veins which finish at
P and Papaver rhoeas, the red corn-poppy. The both ends in a bed of capillary blood vessels. An
corn-poppy is chiefly used as a colouring agent, important example is the hepatic portal system,
its syrup being a brilliant crimson colour. comprising the portal vein and its tributaries.
Blood from the stomach, pancreas, spleen and
Pore intestines drains into the veins that join up to
A small opening. The word is usually used to comprise the portal vein into the liver, where it
describe an opening in the skin that releases branches into sinusoids.
sweat or sebum, a waxy material secreted by the
sebaceous glands in the SKIN. Portal Vein
The vein which carries to the LIVER, blood that
Porphyrias has been circulating in many of the abdominal
A group of rare inherited ENZYME diseases in organs. It is peculiar among the veins of the
which disorders of the metabolic pathways lead- body in that it ends by breaking up into a capil-
ing to the synthesis of HAEM cause excessive lary network instead of carrying the blood dir-
production of haem precursors called PORPHY- ectly to the heart a peculiarity which it shares
RINS by the bone marrow or liver. The excess only with certain small vessels in the kidneys.
porphyrins in the blood mainly affect the skin, The PORTAL SYSTEM begins below in the haem-
causing PHOTOSENSITIVITY, or the central ner- orrhoidal plexus of veins around the lower end
vous system, causing various neuro-psychiatric of the rectum; from this point, along the whole
disorders. Excess porphyrins can be detected in length of the intestines, the blood is collected
blood, urine and faeces. Usually porphyrias are into an inferior mesenteric vein upon the left,
genetically determined, but one form is due to and a superior mesenteric vein upon the right
alcoholic liver disease. The commonest form, side. The inferior mesenteric vein empties into
porphyria cutanea tarda, affects up to 1 in the splenic vein, and the latter, uniting with the
 Post-Partum 569

superior mesenteric vein immediately above the need changing (so are sometimes still found in
pancreas, forms the portal vein. The portal vein situ). They tend to be chosen as a method of
is joined by veins from the stomach and gall- contraception (6 per cent) by older, parous
bladder, and finally divides into two branches women in stable relationships, with a generally
which sink into the right and left lobes of the low problem rate.
liver. (For their further course, see LIVER). Nevertheless, certain problems do occur with
The organs from which the portal vein col- IUCDs, the following being the most common:
lects the blood are the large and small intestines, They tend to be expelled by the uterus in
the stomach, spleen, pancreas, and gall-bladder. women who have never conceived, or by a
uterus distorted by, say, fibroids.
Port Wine Stain ECTOPIC PREGNANCY is more likely.
See NAEVUS. They are associated with pelvic infection and
INFERTILITY, following SEXUALLY TRANS-
Positron-Emission Tomography MITTED DISEASES (STDS) or possibly intro-
(PET) duced during insertion.
See PET SCANNING. They often produce heavy, painful periods
(see MENSTRUATION), and women at high
Possetting risk of these problems (e.g. women who are
The technical term used to describe the quite HIV positive [see AIDS/HIV], or with
common habit of healthy babies to regurgitate, WILSONS DISEASE or cardiac lesions) should
or bring up, small amounts of the meal they generally be excluded unless the IUCD is
have just taken. Its name derives from possett, inserted under antibiotic cover.
an 18th century drink made from porridge and
sherry. Post-Coital Test
A test for INFERTILITY. A specimen of cervical
Post- mucus, taken up to 24 hours after coitus (dur-
A prefix signifying after or behind. ing the post-ovulatory phase of the menstrual
cycle), is examined microscopically to assess the
Post-Coital Contraception motility of the sperms. If motility is above a
Action taken to prevent CONCEPTION after sex- certain level, then sperms and mucus are not
ual intercourse. The type of contraception may interacting abnormally thus eliminating one
be hormonal, or it may be an intrauterine cause of sterility.
device (see below, and under CONTRACEPTION).
Pregnancy after intercourse without contracep- Post-Mortem Examination
tion or where contraception has failed as a Also called an autopsy (and less commonly, nec- P
result, for example, of a leaking condom may ropsy), this is an examination of a body to dis-
be avoided with a course of morning-after cover the causes of death. Such an examination
contraceptive pills. Such preparations usually is sometimes required by law. An unnatural
contain an oestrogen (see OESTROGENS) and a death; a death occurring in suspicious circum-
PROGESTOGEN. Two doses should be taken stances; or a death when a doctor feels unable to
within 72 hours of unprotected intercourse. complete a certificate about the cause all must
An alternative for the woman is to take a high be reported to the CORONER (in Scotland, to
dose of oestrogen on its own. The aim is to the procurator fiscal). He or she may order an
postpone OVULATION and to affect the lining of autopsy to be carried out as part of the inquiry
the UTERUS so that the egg is unable to implant into cause of death. Sometimes doctors may
itself. request the permission of relatives to perform a
post-mortem so that they may discover some-
Intrauterine contraceptive device thing of value for the improvement of medical
(IUCD) This, in effect, is a form of post-coital care. Relatives may refuse consent. (See also
contraception. The IUCD is a plastic shape up DEATH, CAUSES OF.)
to 3 cm long around which copper wire is
wound, carrying plastic thread from its tail. Post-Operative
Colloquially known as a coil, it acts by inhibit- The period after an operation, the patients
ing implantation and may also impair migra- condition after operation, or any investigations
tion of sperm. Devices need changing every 35 or treatment during this time.
years. Coils have generally replaced the larger,
non-copper-bearing inert types of IUCD, Post-Partum
which caused more complications but did not The term applied to anything happening
 570 Post-Traumatic Stress Disorder (PTSD)

immediately after childbirth: for example, post- and VEINS and are used to relieve pain in
partum haemorrhage. (See also PREGNANCY AND ANGINA of the HEART. Nicorandil is the main
LABOUR.) example.

Post-Traumatic Stress Disorder Potassium Permanganate

(PTSD) A salt of the metallic element POTASSIUM. It is
A term introduced to PSYCHIATRY in 1980 after used as a skin antiseptic (see ANTISEPTICS) and
the Vietnam War. It is one of several psychiatric for cleaning wounds; its astringent effect is use-
disorders that can develop in people exposed to ful in the treatment of DERMATITIS. It should
severe trauma, such as a major physical injury, not be taken internally because the compound
participation in warfare, assault or rape, or any is poisonous.
event in which there is major loss of life or a
threat of loss of life. Most people exposed to Potts Disease
trauma do not develop psychiatric disorder; A traditional name often applied to the angular
however, some develop immediate distress and, curvature of the spine which results from tuber-
occasionally, the reaction can be delayed for culous disease. (See SPINE AND SPINAL CORD,
many months. Someone with PTSD has regular DISEASES AND INJURIES OF.) The disease is
recurrences of memories or images of the stress- named after Percivall Pott, an English surgeon
ful event (flashbacks), especially when (171488), who first described the condition.
reminded of it. Insomnia, feelings of guilt and
isolation, an inability to concentrate and irrit- Potts Fracture
ability may result. DEPRESSION is very common. A variety of fractures around the ankle, accom-
Support from friends and family is probably panied by a varying degree of dislocation of the
the best management, but those who do not ankle. In all cases the fibula is fractured. Named
recover quickly can be helped by antidepres- after Percivall Pott, who suffered from this frac-
sants and psychological treatments such as ture and was the first to describe it (see BONE,
COGNITIVE BEHAVIOUR THERAPY. Over the DISORDERS OF), it is often mistaken for a simple
past few years, PTSD has featured increasingly sprain of the ankle.
in compensation litigation.
Pouchitis
Postural Drainage A rare chronic inflammatory disease in the ileal
Facilitation of the drainage of secretions from pouch, which remains after a patient has had
dilated bronchi of the LUNGS. The patient lies intestinal resection because of INFLAMMATORY
on an inclined plane, head downwards, and is BOWEL DISEASE (IBD). Metronidazole and oral
P encouraged to cough up as much secretion PROBIOTICS are effective treatments.
from the lungs as possible. The precise position
depends on which part of the lungs is affected. Poultices
It may need to be carried out for up to three (See also FOMENTATION.) Soft, moist applica-
hours daily in divided periods. It is of particular tions to the surface of the body, generally used
value in BRONCHIECTASIS and lung abscess (see hot to soothe pain due to inflammation and to
LUNGS, DISEASES OF). promote resolution.

Post-Viral Fatigue Syndrome Pouparts Ligament

See MYALGIC ENCEPHALOMYELITIS (ME). Also known as the inguinal ligament, it is the
strong ligament lying in the boundary between
Potassium the anterior abdominal wall and the front of the
A metal which, on account of its great affinity thigh.
for other substances, is not found in a pure state
in nature. Its salts are widely used in medicine Praziquantel
but, as their action depends in general not on An effective drug against all human schisto-
their metallic radical but upon the acid with somes which has a broad spectrum of activity
which it is combined, their uses vary greatly and and low toxicity (see SCHISTOSOMIASIS).
are described elsewhere. All salts of potassium
depress the hearts action as a result of action by Pre-
the potassium ion. A prefix meaning before.

Potassium-Channel Activators Precipitin

Drugs that have the ability to dilate ARTERIES An antibody (see ANTIBODIES) that combines
 Pregnancy and Labour 571

with an ANTIGEN and forms the immune com- a developing baby in her UTERUS. For the first
plex as a precipitate. The reaction is used in 12 weeks (the first trimester) the baby is known
some diagnostic serological tests to identify as an EMBRYO, after which it is referred to as the
antigens in the serum. FETUS.
Pregnancy lasts about 280 days and is calcu-
Precordial Region lated from the first day of the last menstrual
The area on the centre and towards the left side period see MENSTRUATION. Pregnancy-testing
of the chest, lying in front of the heart. kits rely on the presence of the hormone beta
HUMAN CHORIONIC GONADOTROPHIN (b
Prednisolone HCG) which is excreted in the womans urine
A derivative of CORTISONE, which is five or six as early as 30 days from the last menstrual
times as active as cortisone and has less of the period. The estimated date of delivery can be
salt- and water-retaining properties of corti- accurately estimated from the size of the devel-
sone. It is given by mouth. oping fetus measured by ULTRASOUND (see also
below) between seven and 24 weeks. Term
Prednisone refers to the time that the baby is due; this can
This corticosteroid drug has a similar level of range from 38 weeks to 41 completed weeks.
glucocorticoid activity as PREDNISOLONE and is Physical changes occur in early pregnancy
converted to prednisolone in the liver. Though periods stop and the abdomen enlarges. The
prednisone is still in use, prednisolone is the breasts swell, with the veins becoming promin-
most commonly used oral corticosteroid for ent and the nipples darkening. About two in
long-term anti-inflammatory treatment. (See three women will have nausea with a few
CORTICOSTEROIDS; GLUCOCORTICOIDS.) experiencing such severe vomiting as to require
hospital admission for rehydration.
Pre-Eclampsia
A complication of pregnancy (see PREGNANCY Antenatal care The aim of antenatal care
AND LABOUR), of unknown cause, which in is to ensure a safe outcome for both mother and
severe cases may proceed to ECLAMPSIA. It is child; it is provided by midwives (see MIDWIFE)
characterised by HYPERTENSION, renal impair- and doctors. Formal antenatal care began in
ment, OEDEMA, often with PROTEINURIA and Edinburgh in the 1930s with the recognition
disseminated intravascular coagulation. It usu- that all aspects of pregnancy normal and
ally occurs in the second half of pregnancy abnormal warranted surveillance. Cooper-
mild cases (without proteinuria) occurring in ation between general practitioners, midwives
about 10 per cent of pregnancies, severe cases in and obstetricians is now established, with preg-
about 2 per cent. Predisposing factors include a nancies that are likely to progress normally P
first pregnancy, or pregnancy by a new partner; being cared for in the community and only
a family history of pre-eclampsia, hypertension, those needing special intervention being cared
or other cardiovascular disorders; and pre- for in a hospital setting.
existing hypertension or DIABETES MELLITUS. The initial visit (or booking) in the first half
Increased incidence with lower socio-economic of pregnancy will record the history of past
class may be linked to diet or to failure to attend events and the results of tests, with the aim of
for antenatal care. Although less common in categorising the patients into normal or not.
smokers, fetal outlook is worse. Multiple preg- Screening tests including blood checks and
nancy and HYDATIDIFORM MOLE, together with ultrasound scans are a routine part of antenatal
hydrops fetalis (see HAEMOLYTIC DISEASE OF care. The first ultrasound scan is done at about
THE NEWBORN), predispose to early and severe 11 weeks to date the pregnancy, with a further
pre-eclampsia. one done at 20 weeks the anomaly scan to
assess the babys structure. Some obstetric units
Treatment Severe pre-eclampsia is an emer- will check the growth of the baby with one fur-
gency, and urgent admission to hospital should ther scan later in the pregnancy or, in the case of
be arranged. Treatment should be given to con- twin pregnancies (see below), many scans
trol the hypertension; the fetal heart rate care- throughout. The routine blood tests include
fully monitored; and in very severe cases urgent checks for ANAEMIA, DIABETES MELLITUS,
CAESAREAN SECTION may be necessary. sickle-cell disease and THALASSAEMIA, as well as
for the blood group. Evidence of past infections
Pregnancy and Labour is also looked for; tests for RUBELLA (German
measles) and SYPHILIS are routine, whereas tests
Pregnancy The time when a woman carries for human immunodeficiency virus (see AIDS/
 572 Pregnancy and Labour

HIV below) and HEPATITIS are being offered as specimen of urine. In pregnancy, symptoms of
optional, although there is compelling evidence these infections do not necessarily resemble
that knowledge of the mothers infection status those experienced by non-pregnant women. As
is beneficial to the baby. they can cause uterine irritability and possible
Traditional antenatal care consists of regular premature labour (see below), it is important to
appointments, initially every four weeks until find and treat them appropriately.
34 weeks, then fortnightly or weekly. At each ANAEMIA is more prevalent in patients who are
visit the mothers weight, urine and blood pres- vegetarian or on a poor diet. Iron supplements
sure are checked, and assessment of fetal growth are usually given to women who have low con-
and position is done by palpating the uterus. centrations of HAEMOGLOBIN in their blood
Around two-thirds of pregnancies and labours (less than 10.5 g/dl) or who are at risk of
are normal: in the remainder, doctors and mid- becoming low in iron, from bleeding, twin
wives need to increase the frequency of surveil- pregnancies and those with placenta previa (see
lance so as to prevent or deal with maternal and below).
fetal problems. ANTEPARTUM HAEMORRHAGE Early in preg-
nancy, vaginal bleedings may be due to a
Common complications of pregnancy spontaneous or an incomplete therapeutic
Some of the more common complications of ABORTION. Bleeding from the genital tract
pregnancy are listed below. between 24 completed weeks of pregnancy and
As well as early detection of medical compli- the start of labour is called antepartum haemor-
cations, antenatal visits aim to be supportive rhage. The most common site is where the PLA-
and include emotional and educational care. CENTA is attached to the wall of the uterus. If
Women with uncomplicated pregnancies are the placenta separates before delivery, bleeding
increasingly being managed by midwives and occurs in the exposed bed. When the placenta
general practitioners in the community and is positioned in the upper part of the uterus it is
only coming to the hospital doctors should they called an abruption.
develop a problem. A small number will opt for PLACENTA PRAEVIA is sited in the lower part
a home delivery, but facilities for providing and blocks or partly blocks the cervix (neck of
such a service are not always available in the the womb); it can be identified at about the
UK. 34th week. Ten per cent of episodes of ante-
Women requiring more intensive surveil- partum bleeding are caused by placenta
lance have their management targeted to the previa, and it may be associated with bleeding
specific problems encountered. Cardiologists at delivery. This potentially serious complica-
will see mothers-to-be with heart conditions, tion is diagnosed by ultrasound scanning and
P and those at risk of diabetes are cared for in may require a caesarean section (see below) at
designated clinics with specialist staff. Those delivery.
women needing more frequent surveillance INCREASED BLOOD PRESSURE, associated with
than standard antenatal care can be looked after protein in the urine and swelling of the limbs, is
in maternity day centres. These typically part of a condition known as PRE-ECLAMPSIA.
include women with mildly raised blood pres- This occurs in the second half of pregnancy in
sure or those with small babies. Fetal medicine about 1 in 10 women expecting their first baby,
units have specialists who are highly skilled in and is mostly very mild and of no consequence
ultrasound scanning and specialise in the diag- to the pregnancy. However, some women can
nosis and management of abnormal babies still develop extremely high blood pressures which
in the uterus. can adversely affect the fetus and cause
ECTOPIC PREGNANCY Chronic abdominal dis- epileptic-type seizures and bleeding disorders in
comfort early in pregnancy may be caused by the mother. This serious condition is called
unruptured ectopic pregnancy, when, rarely, the ECLAMPSIA. For this reason a pregnant woman
fertilised OVUM starts developing in the Fal- with raised blood pressure or PROTEIN in her
lopian tube (see FALLOPIAN TUBES) instead of urine is carefully evaluated with blood tests,
the uterus. The patient needs hospital treat- often in the maternity day assessment unit. The
ment and LAPAROSCOPY. A ruptured ectopic condition can be stopped by delivery of the
pregnancy causes acute abdominal symptoms baby, and this will be done if the mothers or
and collapse, and the woman will require the fetuss life is in danger. If the condition is
urgent abdominal surgery. milder, and the baby not mature enough for a
URINARY TRACT INFECTIONS These affect safe delivery, then drugs can be used to control
around 2 per cent of pregnant women and are the blood pressure.
detected by a laboratory test of a mid-stream MISCARRIAGE Also called spontaneous abor-
 Pregnancy and Labour 573

tion, miscarriage is the loss of the fetus. There birth using ultrasound. Some of these defects
are several types: are obvious, such as the absence of kidneys, a
threatened miscarriage is one in which some
vaginal bleeding occurs, the uterus is
condition incompatible with life outside the
womb. These women can be offered a termin-
enlarged, but the cervix remains closed and ation of their pregnancy. However, more com-
pregnancy usually proceeds. monly, the pattern of problems can only hint at
inevitable miscarriage usually occurs before
the 16th week and is typified by extensive
an abnormality and closer examination is
needed, particularly in the diagnosis of chromo-
blood loss through an opened cervix and somal deformities such as DOWNS (DOWN)
cramp-like abdominal pain; some products SYNDROME (trisomy 21 or presence of three 21
of conception are lost but the developing chromosomes instead of two).
placental area (decidua) is retained and an Chromosomal abnormalities can be defini-
operation may be necessary to clear the tively diagnosed only by cell sampling such as
womb. amniocentesis (obtaining amniotic fluid see
missed miscarriages, in which the embryo AMNION from around the baby) done at 15
dies and is absorbed, but the decidua (pla- weeks onwards, and chorionic villus sampling
cental area of uterine wall) remains and may (sampling a small part of the placenta)
cause abdominal discomfort and discharge of another technique which can be done from 12
old blood. weeks onwards. Both have a small risk of mis-
THERAPEUTIC ABORTION is performed on carriage associated with them; consequently,
more than 170,000 women annually in Eng- they are confined to women at higher risk of
land and Wales. Sometimes the woman may having an abnormal fetus.
not have arranged the procedure through the Biochemical markers present in the pregnant
usual health-care channels, so that a doctor may womans blood at different stages of pregnancy
see a patient with vaginal bleeding, abdominal may have undergone changes in those carrying
discomfort or pain, and open cervix symp- an abnormal fetus. The first such marker to be
toms which suggest that the decidua and a routinely used was a high concentration of
blood clot have been retained; these retained alpha-fetol protein in babies with SPINA BIFIDA
products will need to be removed by curettage. (defects in the covering of the spinal cord).
Septic abortions are now much less common Fuller research has identified a range of diag-
in Britain than before the Abortion Act (1967) nostic markers which are useful, and, in con-
permitted abortion in specified circumstances. junction with other factors such as age, ethnic
The cause is the passage of infective organisms group and ultrasound findings, can provide a
from the vagina into the uterus, with predictive guide to the obstetrician in con-
Escherichia coli and Streptococcus faecalis the sultation with the woman as to whether or P
most common pathogenic agents. The woman not to proceed to an invasive test. These tests
has abdominal pain, heavy bleeding, usually include pregnancy-associated plasma protein
fever and sometimes she is in shock. The cause assessed from a blood sample taken at 12 weeks
is usually an incomplete abortion or one and four blood tests at 1522 weeks alpha-
induced in unsterile circumstances. Antibiotics fetol protein, beta human chorionic gonado-
and curettage are the treatment. trophin, unconjugated oestriol and inhibin A.
INTRAUTERINE GROWTH RETARDATION de- Ultrasound itself can reveal physical findings in
scribes a slowing of the babys growth. This can the fetus, which can be more common in cer-
be diagnosed by ultrasound scanning, although tain abnormalities. Swelling in the neck region
there is a considerable margin of error in esti- of an embryo in early pregnancy (increased
mates of fetal weight. Trends in growth are nuchal thickness) has good predictive value on
favoured over one-off scan results alone. its own, although its accuracy is improved in
GESTATIONAL DIABETES is a condition that is combination with the biochemical markers.
more common in women who are overweight The effectiveness of prenatal diagnosis is rapidly
or have a family member with diabetes. If high evolving, the aim being to make the diagnosis as
concentrations of blood sugar are found, efforts early in the pregnancy as possible to help the
are made to correct it as the babies can become parents make more informed choices.
very fat (macrosomia), making delivery more MULTIPLE PREGNANCIES In the UK, one in 95
difficult. A low-sugar diet is usually enough to deliveries is of twins, while the prevalence of
control the blood concentration of sugars; how- triplets is one in 10,000 and quadruplets
ever some women need small doses of INSULIN around one in 500,000. Racial variations occur,
to achieve control. with African women having a prevalence rate of
FETAL ABNORMALITIES can be detected before one in 30 deliveries for twins and Japanese
 574 Pregnancy and Labour

women a much lower rate than the UK figure. fits into the maternal pelvis head-first in what is
Multiple pregnancies occur more often in older called the occipito-anterior position, with the
women, and in the UK the prevalence of fertil- babys face pointing towards the back of the
ity treatments, many of these being given to pelvis. Sometimes, however, the head may face
older women, has raised the incidence. There is the other way, or enter the pelvis transversely
now an official limit of three eggs being trans- or, rarely, the babys neck is flexed backwards
ferred to a woman undergoing ASSISTED CON- with the brow or face presenting to the neck of
CEPTION (gamete intrafallopian transfer, or the womb. Some malpositions will correct nat-
GIFT). urally; others can be manipulated abdominally
Multiple pregnancies are now usually diag- during pregnancy to a better position. If, how-
nosed as a result of routine ultrasound scans ever, the mother starts labour with the babys
between 16 and 20 weeks of pregnancy. The head badly positioned or with the buttocks
increased size of the uterus results in the mother instead of the head presenting (breech pos-
having more or worse pregnancy-related condi- ition), the labour will usually be longer and
tions such as nausea, abdominal discomfort, more difficult and may require intervention
backache and varicose veins. Some congenital using special obstetric forceps to assist in
abnormalities in the fetus occur more fre- extracting the baby. If progress is poor and the
quently in twins: NEURAL TUBE defects, fetus distressed, caesarean section may be
abnormalities of the heart and the incidence of necessary.
TURNERS SYNDROME and KLINEFELTERS SYN- HIV INFECTION Pregnant women who are HIV
DROME are examples. Such abnormalities may positive (see HIV; AIDS/HIV) should be taking
be detected by ultrasound scans or amnio- antiviral drugs in the final four to five months
centesis. High maternal blood pressure and of pregnancy, so as to reduce the risk of infect-
anaemia are commoner in women with mul- ing the baby in utero and during birth by
tiple pregnancies (see above). around 50 per cent. Additional antiviral treat-
The growth rates of multiple fetuses vary, but ment is given before delivery; the infection risk
the difference between them and single fetuses to the baby can be further reduced by about
are not that great until the later stages of preg- 40 per cent if delivery is by caesarean section.
nancy. Preterm labour is commoner in multiple The mother may prefer to have the baby nor-
pregnancies: the median length of pregnancy is mally, in which case great care should be taken
40 weeks for singletons, 37 for twins and 33 for not to damage the babys skin during delivery.
triplets. Low birth-weights are usually the result The infection risk to the baby is even further
of early delivery rather than abnormalities in reduced if it is not breast fed. If all preventive
growth rates. Women with multiple pregnan- precautions are taken, the overall risk of the
P cies require more frequent and vigilant ante- infant becoming infected is cut to under 5 per
natal assessments, with their carers being alert cent.
to the signs of preterm labour occurring.
CEPHALOPELVIC DISPROPORTION Disparity Premature birth This is a birth that takes
between the size of the fetus and the mothers place before the end of the normal period of
pelvis is not common in the UK but is a signifi- gestation, usually before 37 weeks. In practice,
cant problem in the developing world. Dispar- however, it is defined as a birth that takes place
ity is classified as absolute, when there is no when the baby weighs less than 25 kilograms
possibility of delivery, and relative, when the (5 pounds). Between 5 and 10 per cent of
baby is large but delivery (usually after a dif- babies are born prematurely, and in around 40
ficult labour) is possible. Causes of absolute per cent of premature births the cause is
disparity include: a large baby heavier than unknown. Pre-eclampsia is the most common
5 kg at birth; fetal HYDROCEPHALUS; and an known cause; others include hypertension,
abnormal maternal pelvis. The latter may be chronic kidney disease, heart disease and dia-
congenital, the result of trauma or a contraction betes mellitus. Multiple pregnancy is another
in pelvic size because of OSTEOMALACIA early in cause. In the vast majority of cases the aim of
life. Disproportion should be suspected if in management is to prolong the pregnancy and so
late pregnancy the fetal head has not engaged improve the outlook for the unborn child. This
in the pelvis. Sometimes a closely supervised consists essentially of rest in bed and sedation,
trial of labour may result in a successful, if but there are now several drugs, such as RITO-
prolonged, delivery. Otherwise a caesarean sec- DRINE, that may be used to suppress the activity
tion (see below) is necessary. of the uterus and so help to delay premature
UNUSUAL POSITIONS AND PRESENTATIONS OF labour. Prematurity was once a prime cause of
THE BABY In most pregnant women the baby infant mortality but modern medical care has
 Pregnancy and Labour 575

greatly improved survival rates in developing touse). If the cervix is not completely dilated or
countries. open and the head not descended, then an
emergency caesarean section may need to be
Labour Also known by the traditional terms done to deliver the baby. This procedure
parturition, childbirth or delivery, this is the involves delivering the baby and placenta
process by which the baby and subsequently the through an incision in the mothers abdomen.
placenta are expelled from the mothers body. It is sometimes necessary to deliver by planned
The onset of labour is often preceded by a or elective caesarean section: for example, if
show the loss of the mucus and blood plug the placenta is low in the uterus called pla-
from the cervix, or neck of the womb; this centa praevia making a vaginal delivery
passes down the vagina to the exterior. The time dangerous.
before the beginning of labour is called the The third stage occurs when the placenta (or
latent phase and characteristically lasts 24 afterbirth) is delivered, which is usually about
hours or more in a first pregnancy. Labour itself 1020 minutes after the baby. An injection of
is defined by regular, painful contractions ergometrine and oxytocin is often given to
which cause dilation of the neck of the womb women to prevent bleeding.
and descent of the fetal head. Breaking of the Pain relief in labour varies according to the
waters is the loss of amniotic fluid vaginally mothers needs. For uncomplicated labours,
and can occur any time in the delivery process. massage, reassurance by a birth attendant, and a
Labour itself is divided into three stages: the warm bath and mobilisation may be enough for
first is from the onset of labour to full (10 cm) some women. However, some labours are pain-
dilation of the neck of the womb. This stage ful, particularly if the woman is tired or anxious
varies in length, ideally taking no more than or is having her first baby. In these cases other
one hour per centimetre of dilation. Progress is forms of analgesia are available, ranging from
monitored by regular vaginal examinations, inhalation of NITROUS OXIDE GAS, injection of
usually every four hours. Fetal well-being is PETHIDINE HYDROCHLORIDE or similar nar-
observed by intermittent or continuous moni- cotic, and regional local anaesthetic (see
toring of the fetal heart rate in relation to the ANAESTHESIA).
timing and frequency of the contractions. The Once a woman has delivered, care continues
print-out is called a cardiotocograph. to ensure her and the babys safety. The mid-
Abnormalities of the fetal heart rate may sug- wives are involved in checking that the uterus
gest fetal distress and may warrant intervention. returns to its normal size and that there is no
In women having their first baby (primi- infection or heavy bleeding, as well as caring for
gravidae), the common cause of a slow labour is stitches if needed. The normal blood loss after
uncoordinated contractions which can be birth is called lochia and generally is light, last- P
overcome by giving either of the drugs ing up to six weeks. Midwives offer support
PROSTAGLANDIN or OXYTOCIN, which provoke with breast feeding and care of the infant and
contractions of the uterine muscle, by an intra- will visit the parents at home routinely for up to
venous drip. Labours which progress slowly or two weeks.
not at all may be due to abnormal positioning
of the fetus or too large a fetus, when prosta- Some complications of labour All
glandin or oxytocin is used much more operative deliveries in the UK are now done in
cautiously. hospitals, and are performed if a spontaneous
The second stage of labour is from full cer- birth is expected to pose a bigger risk to the
vical dilation to the delivery of the baby. At mother or her child than a specialist-assisted
this stage the mother often experiences an one. Operative deliveries include caesarean sec-
irresistible urge to push the baby out, and a tion, forceps-assisted deliveries and those in
combination of strong coordinated uterine con- which vacuum extraction (ventouse) is used.
tractions and maternal effort gradually moves CAESAREAN SECTION Absolute indications for
the baby down the birth canal. This stage usu- this procedure, which is used to deliver over 15
ally lasts under an hour but can take longer. per cent of babies in Britain, are cephalopelvic
Delay, exhaustion of the mother or distress of disproportion and extensive placenta praevia,
the fetus may necessitate intervention by the both discussed above. Otherwise the decision to
midwife or doctor. This may mean enlarging undertake caesarean section depends on the
the vaginal opening with an EPISIOTOMY (cut- clinical judgement of the specialist and the
ting of the perineal outlet see below) or views of the mother. The rise in the proportion
assisting the delivery with specially designed of this type of intervention (from 5 per cent in
obstetric forceps or a vacuum extractor (ven- the 1930s to its present level of over 23 per cent
 576 Pregnancy and Labour

of the 600,000 or so annual deliveries in Eng- opened and then her uterus opened slowly with
land) has been put down to defensive medicine a transverse incision and the baby carefully
namely, the doctors fear of litigation (initi- extracted. A transverse incision is used in pref-
ated often because the parents believe that the erence to the traditional vertical one as it
babys health has suffered because the mother enables the woman to have a vaginal delivery in
had an avoidably difficult natural labour). In any future pregnancy with a much smaller risk
Britain, over 60 per cent of women who have of uterine rupture. Women are usually allowed
had a caesarean section try a vaginal delivery in to get up within 24 hours and are discharged
a succeeding pregnancy, with about two-thirds after four or five days.
of these being successful. Indications for the FORCEPS AND VENTOUSE DELIVERIES Obstetric
operation include: forceps are made in several forms, but all are
absolute and relative cephalopelvic basically a pair of curved blades shaped so that
disproportion. they can obtain a purchase on the babys head,
placenta previa. thus enabling the operator to apply traction and
fetal distress. (usually) speed up delivery. (Sometimes they are
prolapsed umbilical cord this endangers the
viability of the fetus because the vital supply
used to slow down progress of the head.) A ven-
touse or vacuum extractor comprises an egg-
of oxygen and nutrients is interrupted. cup-shaped metal or plastic head, ranging from
malpresentation of the fetus such as breech
or transverse lie in the womb.
40 to 60 mm in diameter with a hollow tube
attached through which air is extracted by a
unsatisfactory previous pregnancies or foot-operated vacuum pump. The instrument
deliveries. is placed on the descending head, creating a
a request from the mother.
Caesarean sections are usually performed
negative pressure on the skin of the scalp and
enabling the operator to pull the head down. In
using regional block anaesthesia induced by a mainland Europe, vacuum extraction is gener-
spinal or epidural injection. This results in loss ally preferred to forceps for assisting natural
of feeling in the lower part of the body; the deliveries, being used in around 5 per cent of all
mother is conscious and the baby not exposed deliveries. Forceps have a greater risk of causing
to potential risks from volatile anaesthetic gases damage to the babys scalp and brain than vac-
inhaled by the mother during general anaes- uum extraction, although properly used, both
thesia. Post-operative complications are higher types should not cause any serious damage to
with general anaesthesia, but maternal anxiety the baby.
and the likelihood that the operation might be
complicated and difficult are indications for Episiotomy Normal and assisted deliveries
P using it. A general anaesthetic may also be put the tissues of the genital tract under strain.
required for an acute obstetric emergency. At The PERINEUM is less elastic than the vagina
operation the mothers lower abdomen is and, if it seems to be splitting as the babys head

Cephalic (left) and breech (right) presentation of fetus in maternal pelvis at term.
 Premedication 577

moves down the birth canal, it may be necessary The haemagglutination inhibition
to cut the perineal tissue a procedure called an test This, and the subsequent tests to be men-
episiotomy to limit damage. This is a simple tioned, are known as immunological tests. They
operation done under local anaesthetic. It are based upon the effect of the urine from a
should be done only if there is a specific indica- pregnant woman upon the interaction of red
tion; these include: blood cells, which have been sensitised to
to hasten the second stage of labour if the
fetus is distressed.
human gonadotrophin, and
gonadotrophin serum. They have the great
anti-

to facilitate the use of forceps or vacuum practical advantage of being performed in a

extractor. test-tube or even on a slide. Because of their
to enlarge a perineum that is restricted
because of unyielding tissue, perhaps because
ease and speed of performance, a result can be
obtained in two hours.
of a scar from a previous labour.
Midwives as well as obstetricians are trained Enzyme-linked immunosorbent assay
to undertake and repair (with sutures) (ELISA) This is the basis of many of the
episiotomies. pregnancy-testing kits obtainable from pharma-
(For organisations which offer advice and cies. It is a highly sensitive antibody test and can
information on various aspects of childbirth, detect very low concentrations of human chori-
including eclampsia, breast feeding and mul- onic gonadotrophin. Positive results show up as
tiple births, see APPENDIX 2: ADDRESSES: early as ten days after fertilisation namely, four
SOURCES OF INFORMATION, ADVICE, SUPPORT days before the first missed period.
AND SELF-HELP.)
Ultrasound The fetal sac can be detected by
Psychological and social problems ULTRASOUND from five weeks, and a fetal echo
Any previously existing mental-health prob- at around six or seven weeks (see also PRENATAL
lems may worsen under the stress of pregnancy SCREENING OR DIAGNOSIS).
and childbirth, and a womans socio-economic
circumstances may be an influential factor. Pregnandiol
Mood swings are common in pregnant women The excretion product of the hormone, PRO-
and mothers of new babies; sympathetic sup- GESTERONE, manufactured by the corpus
port from staff and relations will usually remedy luteum of the ovary (see OVARIES). Pregnandiol
the situation. If postnatal depression lasts for is excreted in the urine during the second half
more than a week or two the use of mild ANTI- of the menstrual period, and its excretion rises
DEPRESSANT DRUGS may be justified. If depres- steadily throughout pregnancy.
sion persists, referral to a psychiatrist may be P
advisable. Rarely, severe psychiatric problems Premature Beat
puerperal psychosis may develop during or See ECTOPIC BEAT.
after pregnancy and referral to an appropriate
psychiatric unit is then essential. If the mothers Premature Birth
social circumstances are unsatisfactory, advice See ABORTION; FETUS; PREGNANCY AND
should be sought from social services depart- LABOUR.
ments. Mothers may also need advice on bene-
fits to which they are entitled and how to claim Premature Ejaculation
them. Benefits Agency offices or Citizens A disorder in which EJACULATION of semen
Advice Bureaux as well as antenatal clinics are occurs before or immediately after the penis
useful sources of information. penetrates the vagina during sexual intercourse.
The most common sexual problem in men,
Pregnancy Tests persistent premature ejaculation may have
There are several tests for pregnancy (see PREG- psychological causes, although many adoles-
NANCY AND LABOUR) in its early stages, and cents and some adults experience it occasion-
these can be done on blood or urine; some of ally. Sexual counselling may help to alleviate the
the urine tests may be carried out at home. condition.
Most tests are based on the detection of
HUMAN CHORIONIC GONADOTROPHIN (HCG) Premedication
in the womans urine. They are nearly 100 per A drug or drugs given to a patient to produce
cent accurate and may show positive as early as sedation before an operation, whether this is
30 days after the first day of the last normal done under a local or general anaesthetic. A
period. narcotic analgesic drug (see NARCOTICS;
 578 Premenstrual Syndrome

ANALGESICS) is usually used, as this relieves pain as SPINA BIFIDA and CLEFT PALATE and even
as well as anxiety. An antisecretory drug is often cardiac and renal problems. A series of scans can
added to reduce the secretions in the airways assess whether the baby is growing at a normal
and thus lessen the risk associated with general rate; ultrasound may also be used to assist with
anaesthesia. Premedication reduces the amount other diagnostic tests (e.g. AMNIOCENTESIS
of anaesthetic needed to make the patient see below).
unconscious. Tests on the mothers blood can also diag-
nose fetal abnormalities. Alphafetoprotein
Premenstrual Syndrome (AFP) is produced by babies and leaks into the
This has been defined as any combination of AMNIOTIC FLUID and is absorbed by the
emotional or physical features which occur cyc- mother. In spina bifida and other neural-tube
lically in a woman before MENSTRUATION, and defects there is increased leakage of AFP, and a
which regress or disappear during menstru- blood test at 16 weeks gestation can detect a
ation. It is characterised by mood-changes, dis- raised level which suggests the presence of these
comfort, swelling and tenderness in the breasts, abnormalities.
swelling of the legs, a bloated feeling in the The triple test, also performed at 16 weeks,
abdomen, headache, fatigue and constipation. measures AFP and two hormones HUMAN
The mood-changes range from irritability and CHORIONIC GONADOTROPHIN and unconju-
mild depression to outbursts of violence. It may gated OESTRADIOL and is used in diagnosing
last for 314 days. How common it is is not DOWNS (DOWN) SYNDROME.
known, as only the more severe cases are seen Amniocentesis involves inserting a needle
by doctors, but it has been estimated that one through the mothers abdominal wall into the
in ten of all menstruating women suffer from it uterus to remove a sample of amniotic fluid at
severely enough to require treatment. The 1618 weeks. Examination of the fluid and the
cause is not known, but it is probably due to cells it contains is used in the diagnosis of
some upset of the hormonal balance of the Downs syndrome and other inherited dis-
body. In view of the multiplicity of causes that orders. The test carries a small risk of
have been put forward, it is not surprising that miscarriage.
there is an equal multiplicity of treatments. Chorionic villus sampling may be used to
Among these, one of the most widely used is diagnose various inherited conditions. A small
PROGESTERONE. Others include pyridoxine, amount of tissue from the developing PLA-
danazol, and gamma linolenic acid available in CENTA is removed for analysis: this test has the
the form of oil of evening primrose. Whatever advantages of having a lower incidence of mis-
drug may be prescribed, counselling is equally carriage than amniocentesis and is carried out at
P essential and, in many cases, is all that is an earlier stage (913 weeks).
required. Analysis of a blood sample removed from the
umbilical cord (cordocentesis) may diagnose
Premolar infections in the uterus, blood disorders or
The two TEETH on each side of the jaw posi- inherited conditions.
tioned between the canines and the molars in Direct observation of the fetus via a viewing
the adult. The teeth are used with the molars instrument called a fetoscope is also used diag-
for holding and grinding food. nostically and will detect structural
abnormalities.
Prenatal Screening or Diagnosis Most tests have a recognised incidence of
Prenatal screening of fetal abnormalities may false positive and negative results and are there-
be the result of screening tests carried out on fore usually cross-checked with another test.
most or all pregnant women, or as the result Counselling of the parents about prenatal tests
of specific diagnostic tests performed to detect is important. This allows them to make an
specific conditions. Prenatal diagnosis is informed choice which may not necessarily
important as it will identify babies who might involve terminating the pregnancy if an
need medical or surgical treatment before or abnormality is found. (See PREGNANCY AND
soon after birth. In addition, it may also LABOUR.)
detect severe abnormalities for which
parents might decide to have a therapeutic Prepuce
ABORTION. Also known as the foreskin, this is the free fold
ULTRASOUND scanning is probably the most of skin that overlaps the glans PENIS and retracts
widely used diagnostic tool in obstetric prac- when the penis becomes erect. It is the part that
tice. It can detect structural abnormalities such is removed at CIRCUMCISION.
 Preventive Medicine 579

Presbyacusis Computer-generated prescriptions

DEAFNESS that comes on with increasing years. The Royal College of General Practitioners
It is caused by increasing loss of elasticity in the has issued guidelines on the use of computer-
hearing mechanism, combined with the slow- generated prescriptions for drugs other than
ing-down of the mental processes that accom- controlled drugs. The guidelines include rules
panies old age. It is characterised by particular on giving the patients name, address and date
difficulty in hearing high notes such as the tele- of birth with the responsible prescribing doc-
phone and the voices of women and children. tors name at the bottom, along with his or her
Hearing in a background of noise is also surgery address and telephone number. The
affected. Modern, miniaturised, transistor prescription has to be signed by the doctor. Sev-
within-the-ear hearing aids are now available eral other requirements are included to min-
that are proving helpful in making life more imise the risk of prescription-tampering, fraud
bearable for the elderly in this respect. (See also or the inclusion of identifiable confidential
AGEING; HEARING AIDS.) information. Full details of the guidelines
appear in the British National Formulary, pub-
Presbyopia lished every six months.
See ACCOMMODATION; EYE, DISORDERS OF.
Presenile
Prescribed Diseases Describing the condition of premature AGEING.
A collection of industrial diseases which provide The mental and physical faculties are adversely
those with a disease legal entitlement to welfare affected in presenility to an extent that does not
benefits. Examples are DEAFNESS from excessive usually occur until old age. (See also DEMENTIA.)
noise in the workplace; ANTHRAX from farm-
ing; PNEUMOCONIOSIS from industrially gener- Presentation
ated dust (coal mining); and LEAD POISONING The appearance in labour of some particular
from the handling of chemicals. (See also OCCU- part of the childs body at the mouth of the
PATIONAL HEALTH, MEDICINE AND DISEASES.) uterus (see PREGNANCY AND LABOUR). This is a
head presentation in 96 per cent of cases, but in
Prescription a certain number the breech (or buttocks) may
The written direction for drugs for medicinal present, or the face, or foot, or even a part of the
use, given by the doctor, dentist and (for some trunk in cases of cross-birth.
drugs) nurse to the patient, for dispensation by The term is also used for the symptoms or
the pharmacist. Drugs should only be pre- signs with which a patient first brings to a
scribed when essential for treatment, and when doctor.
any possible risks involved to the patient (and P
fetus in cases of pregnancy) are outweighed by Pressor
the potential benefits of giving the drug. When An agent that raises the BLOOD PRESSURE.
possible, non-proprietary, or generic, titles
should be prescribed; by allowing the pharma- Pressure Sores
cist to dispense any equivalent drug this avoids See ULCER Decubitus ulcer.
delay for the patient, as well as reducing the cost
to the Health Service. Dosage is generally stated Prevalence
in metric units, and both the amount and fre- An epidemiological term describing the propor-
quency should be carefully explained to the tion of a defined group in the population hav-
patient by the doctor, and clearly written when ing a condition at one point in time. It is an
the drug is dispensed (see also DOSAGE; DRUGS). appropriate measure only in relatively stable
Strict adherence to the Misuse of Drugs Act conditions for example, chronic bronchitis
1973 is necessary to restrict the inappropriate and is not suitable for measuring acute illnesses.
prescription and abuse of drugs, particularly
CONTROLLED DRUGS. Full details of drugs Preventive Medicine
available on NHS prescription are given in the The term preventive medicine may be used
British National Formulary, which is published both in a general lay sense and to cover a spe-
by the British Medical Association and the cific range of activities carried out by health
Royal Pharmaceutical Society of Great Britain professionals. The definition and scope vary
twice a year and distributed to all NHS doctors from country to country. Some people use the
by the government. Careful monitoring of pre- term widely and almost synonymously with
scribing in the UK is carried out by a public health; others limit its use to specific
government-appointed agency. measures directed at individuals, such as an
 580 Preventive Medicine

immunisation against an infectious disease, pre- An example of the latter is CHOLESTEROL

ferring other terms such as health promotion measurement as part of assessing an individuals
for educational activities and health protection risk of developing ischaemic heart disease (see
to cover consumer-protection regulations such under HEART, DISEASES OF). If it is significantly
as food inspection. The preventive approach is raised, dietary or drug treatment can be
an essential component of a broader public- advised.)
health strategy, and, for example, in relation to
diet and physical activity a normal part of the Tertiary prevention aims at minimising
lifestyle of many in the population. the consequences for a patient who already has
In Britain, for instance, preventive medicine the disease (e.g. advising people to take more
is usually taken to encompass a range of activ- exercise and stop smoking after a heart attack).
ities whose purpose is:
to reduce the chance of a person contracting
a disease or becoming disabled.
Many prefer to limit the term preventive
medicine to primary and secondary preven-
to identify either an increased susceptibility tion, emphasising the focus on risk-reducing
to develop a disease, or an early manifest- interventions targeted at well individuals.
ation of a disease at a stage which will still Others prefer the wider emphasis because of the
allow treatment to be effective. importance of a preventive approach in
The American College of Preventive Medi- reducing further disability by recognising and
cine (1983) defined it as a specialised field of treating symptoms early. This can be particu-
medical practice composed of distinct discip- larly important in older people, where, for
lines which utilise skills focusing on the health example, vigorous treatment of an orthopaedic
of defined populations in order to promote and problem can enable the patient to maintain
maintain health and well-being and to prevent physical mobility with all the benefits to health
disease, disability and premature death. that brings. Whether primary, secondary or ter-
However defined, the spectrum of activities tiary prevention, some form of screening ques-
encompassed by preventive medicine is wide tion or test is normally necessary to identify a
and includes actions, such as counselling about problem.
lifestyle, where there may not be a clear cut-off The range and extent of opportunities for
between a preventive and a curative act. For prevention are expanding as research identifies
example, advice about smoking and exercise to the causes of diseases and more effective
a recent victim of a myocardial infarction (see treatment becomes feasible. Inevitably there is
under HEART, DISEASES OF) is both essential to economic and political debate about the
treatment and preventive against a future cost-effectiveness of prevention versus cure, as
P attack. Action aimed at a whole population well as about the ETHICS. The situation varies in
such as the addition of fluoride to drinking- relation to the natural history of the specific
water to protect against dental caries (see under disease. Some conditions can easily be pre-
TEETH, DISORDERS OF) is part of a vented but once contracted cannot be cured
population-based public-health strategy but (e.g. RABIES); others are easily cured but are not
would also be widely regarded as preventive yet preventable.
medicine.
A common and widely accepted classification Screening Screening involves carrying out
of preventive medicine is as follows: tests either to identify a treatable disease at a
very early stage, before it has caused symptoms
Primary prevention which aims at the or damage; or to identify a risk factor which can
complete avoidance of a disease (for example, lead to a disease. The tests might be by simple
by immunising a child against an infectious dis- questioning (e.g. Do you smoke cigarettes?
ease see IMMUNISATION). this predicts a considerable increase in the risk
of chronic bronchitis, heart disease, bronchial
Secondary prevention which aims at cancer and many other diseases, and enables
detecting and curing a disease at an early stage targeted advice and help to stop smoking to be
before it has caused any symptoms. This given). Other screening tests involve carrying
requires screening procedures to detect either out complex special investigations such as
the early pre-symptomatic condition, or a risk blood tests or the microscopic investigations of
factor which may lead to it. (An example of the cells for example, for precancerous changes.
former is cervical cytology, where a sample of Many conditions can be identified at an early
cells is scraped from the cervix of the UTERUS stage before they cause symptoms or signs of
and examined microscopically for abnormality. disease and in time for effective treatment to be
 Prion 581

carried out. Inevitably, some of the screening occurring without sexual stimulation. It is a rare
tests proposed can be expensive (particularly if but acute condition that requires immediate
used in large populations), painful or inaccurate treatment. The cause is the failure of blood to
and may not improve the results of treatment. drain from the spongy corpus caversonum tis-
Screening can also provoke considerable anxiety sues of the penis, thus maintaining an erection.
in those waiting for tests or results. Therefore, This may happen because of infection, damage
over the years considerable research has been to the nerves controlling the blood vessels, or a
carried out into the appropriateness and ethics clotting defect in the blood.
of screening, and the World Health Organisa-
tion in 1968 identified a set of rules for evaluat- Prickly Heat
ing screening tests: See MILIARIA.
The condition sought should be an import-
ant health problem, for which there should Primary Care Trust
be an accepted treatment for patients with See GENERAL PRACTITIONER (GP)
recognised disease.
Facilities for diagnosis and treatment should
be available if a case is found.
Primary Health Care
Sometimes called primary medical care, this is
The screening test or examination must be the care provided by a GENERAL PRACTITIONER
suitable and valid. A false positive test will (GP) traditionally entitled the family doctor
cause massive anxiety and also considerable or other health professionals who have first
expense in proving that there is no disease. contact with a patient needing or wanting
Similarly, false negatives can lead people to be medical attention. In the NHS, the primary
reassured and to ignore serious symptoms health-care services include those provided by
until too late. If large numbers of positive tests the general, dental, ophthalmic and pharma-
or false positives occur during a screening pro- ceutical services as well as the family doctor
gramme, health services can be swamped. service. Community health services provided
The test, and any treatment as a possible
result, should be acceptable. For example,
outside the hospitals also offer some primary
health care.
there is little point in screening for a fetal
abnormality which, if found, would lead to a Primidone
recommendation for termination if the A barbiturate-related drug (see BARBITURATES)
mother will refuse it on religious or moral used to treat all forms of EPILEPSY, except in
grounds. sufferers who do not have seizures.
Screening tests also need to be considered
from an economic perspective and the cost of Primigravida P
case-finding (including diagnosis and treat- A woman who is undergoing her first preg-
ment of patients diagnosed) balanced in rela- nancy (see PREGNANCY AND LABOUR).
tion to possible expenditure on medical care
as a whole. Primipara
Finally the programme should reflect the The term applied to a woman who has given
natural history of the disease, and case- birth, or is giving birth, to her first child (see
finding should normally be a continuing PREGNANCY AND LABOUR).
process and not a once for all project.
If these rules are followed, considerable Prion
benefits can result from well-planned and well- An aberrant variety of one of the proteins,
managed screening programmes, and they form called PrP, in a brain cell. The result of a gene
an important part of any health-care system. mutation (see GENES), prions are stable, resistant
The extent to which manipulation of genetic to radiation and impervious to the normal cel-
material will be added to more traditional lular processes of degradation. They seem to
approaches such as counselling, immunisation react with normal PrP, turning it into an
and drug treatment cannot yet be predicted abnormal type that then accumulates in brain
but, as time goes by, it is often likely to be tissue. Prions are believed to be the infectious
ethical and social controls which limit devel- agents that cause a group of serious neurological
opments rather than technical and scientific disorders called spongiform encephalopathies.
limits. CREUTZFELDT-JAKOB DISEASE (CJD), the new
variant of CJD linked with BOVINE SPONGI-
Priapism FORM ENCEPHALOPATHY (BSE), and KURU a
A persisting painful ERECTION of the PENIS neurological disorder found in a cannibal tribe
 582 Private Health Care

in New Guinea are all diseases in this group worsening the level of BED-BLOCKING by elderly
that occur in humans. The prion disorders have patients who do not require hospital-intensity
a long latent period between infection and nursing but who lack family support in the
manifestation of symptoms; they are hard to community and cannot afford private care.
diagnose until autopsy and there is no cure as
yet. Pro-
A prefix meaning forwards.
Private Health Care
The provision of medical and dental care to Probe
patients who pay for the care either directly, A slender, flexible instrument, usually made of
through private medical insurance, or through metal, designed for introduction into a wound
employer-funded private insurance. In the UK, or cavity to explore its depth and direction, to
most patients are treated and cared for by the discover the presence of foreign bodies, or to
community- or hospital-based NHS. Although introduce medicinal substances.
not forbidden to do so, few NHS general prac-
titioners see private patients. NHS consultants Probenecid
are within certain prescribed circumstances A benzoic-acid derivative which interferes with
allowed to treat private patients and many, the excretion by the KIDNEYS of certain com-
especially surgeons, do so; but consultations pounds, including PENICILLIN and PARA-AMINO
and treatment are usually done on private- SALICYLIC ACID. Probenecid and was originally
health premises. Some NHS hospitals have pri- introduced into medicine for this reason, as a
vate facilities attached, but most private care is means of increasing and maintaining the con-
carried out in separate, privately run clinics and centration of penicillin in the body; it is also
hospitals. used to treat chronic GOUT.
Certain specialties for example, ortho-
paedic and reconstructive/cosmetic surgery and
mental health attract more private patients Probiotics
than others, such as paediatrics or medicine for Viable BACTERIA that colonise the intestine and
the elderly. The standards of clinical care are alter the microflora and their metabolic activ-
generally the same in the two systems, but pri- ities, with a presumed beneficial effect for the
vate patients can see the specialist of their host. Many probiotics are LACTIC ACID bacteria
choice at a time convenient to them. Waiting for example, LACTOBACILLUS or bifidobacte-
times for consultations and treatment are short rium. Not all probiotics have the same proper-
and, when in hospital, private patients usually ties or effectiveness. To be effective, a probiotic
have their own room, telephone, TV, open visit- must survive passage through the stomach an
P acid environment and successfully colonise in
ing hours, etc.
A substantial proportion of private medical- the intestines, even when antibiotics are pres-
care services are those provided for elderly ent. Research suggests that probiotics amelior-
people requiring regular nursing care and some ate the symptoms of childhood and travellers
DIARRHOEA, reducing the period of acute
medical supervision. The distinction between
residential care and nursing care for the elderly symptoms particularly if the infection is
is often blurred, but the government policy of caused by one of the ROTAVIRUSES.
providing means-tested state funding only for
people genuinely needing regular nursing care Procainamide Hydrochloride
a system operated by local-authority social- A derivative of PROCAINE, used to treat certain
service departments in England and Wales has cardiac arrythmias (irregularities in the
necessitated clearer definitions of the facilities heartbeat).
provided for the elderly by private organisa-
tions. The strict criteria for state support (espe- Procaine
cially in England), the budget-conscious Once used widely as a local anaesthetic, but
approach of local authorities when negotiating rarely so now.
fees with private nursing homes, and the fact
that NHS hospital trusts also have to pay for Procarbazine
some patients discharged to such homes (to An antineoplastic drug used mainly to treat
free-up hospital beds for new admissions) have Hodgkins disease (see under LYMPHOMA). It acts
led to intense financial pressures on private by interfering with the process of MITOSIS, the
facilities for the elderly. This has caused the method by which the cells of the body, includ-
closure of many homes, which, in turn, is ing tumours, reproduce themselves.
 Prolactin 583

Prochlorperazine Prognathism
Prochlorperazine is an antipsychotic phenothi- Abnormal protusion of the lower JAW, or some-
azine drug (see NEUROLEPTICS). It is also an times of both jaws. The condition may make
effective drug for the prevention or treatment of biting and chewing difficult, in which case
vomiting, and has therefore been used in the corrective surgery is necessary.
treatment of MENIRES DISEASE.
Prognosis
Procidentia The term applied to a forecast as to the prob-
Another term for PROLAPSE. able result of an illness or disease, particularly
with regard to the prospect of recovery.
Proctalgia
Nerve pain in the ANUS or RECTUM, without Proguanil Hydrochloride
any local disease to account for it. Proctalgia A synthetic antimalarial drug usually used with
fugax is a condition more common in men, CHLOROQUINE to prevent infection with MAL-
characterised by cramp-like pains in the rectum ARIA. Occasionally the drug is used to treat
and occasionally accompanied by a feeling of uncomplicated falciparum malaria in combin-
faintness. Occurring at night and lasting up to ation with atovaquone.
15 minutes, the cause is unknown, but is prob-
ably due to muscle spasm. Rapid relief may be Prolactin
achieved by taking food or drink, exerting peri- Prolactin is the pituitary hormone (see PITUIT-
neal pressure (including inserting a finger into ARY GLAND) which initiates lactation. The
the rectum), or sucking a 1 mg tablet of GLYC- development of the breasts during pregnancy is
ERYL TRINITRATE. ascribed to the action of OESTROGENS; pro-
lactin starts them secreting. If lactation does not
Proctitis occur or fails, it may be started by injection of
Inflammation situated about the RECTUM or prolactin.
ANUS. The secretion of prolactin is normally kept
under tonic inhibition by the secretion of
Prodromata DOPAMINE which inhibits prolactin. This is
A term applied to the earliest symptoms of a formed in the HYPOTHALAMUS and secreted
disease, or those which give warning of its into the portal capillaries of the pituitary stalk
presence. to reach the anterior pituitary cells. Drugs that
deplete the brain stores of dopamine or
Progeria antagonise dopamine at receptor level will cause
Premature old age (see also AGEING). HYPERPROLACTINAEMIA and hence the secre- P
tion of milk from the breast and AMENOR-
Progesterone RHOEA. METHYLDOPA and RESERPINE deplete
The hormone of the CORPUS LUTEUM of the brain stores of dopamine and the PHENO-
ovary (see OVARIES). After the escape of the THIAZINES act as dopamine antagonists at
OVUM from the ruptured follicle, the corpus receptor level. Other causes of excess secretion
luteum secretes progesterone, which stimulates of prolactin are pituitary tumours, which may
the growth and secretion of the endometrial be minute and are then called microadenomas,
glands of the UTERUS during the 14 days before or may actually enlarge the pituitary fossa and
MENSTRUATION. In the event of pregnancy, the are then called macroadenomas. The most
secretion of progesterone continues until the common cause of hyperprolactinaemia is a pitu-
babys birth. (See also NORETHISTERONE; PREG- itary tumour. The patient may present with
NANDIOL; CONTRACEPTION.) infertility because patients with hyperprolac-
tinaemia do not ovulate or with amenorrhea
Progestogen and even GALACTORRHOEA.
One of a naturally occurring or synthetically BROMOCRIPTINE is a dopamine agonist.
produced group of steroid HORMONES, includ- Treatment with bromocriptine will therefore
ing PROGESTERONE, that help to maintain control hyperprolactinaemia, restoring normal
normal pregnancy. Progestogens are used in menstruation and ovulation and suppressing
contraceptives (see CONTRACEPTION) and are galactorrhoea. If the cause of hyperprolactin-
useful in treating AMENORRHOEA, premenstrual aemia is an adenomatous growth in the pituit-
tension, and abnormal uterine bleeding. ary gland, surgical treatment should be
considered.
 584 Prolapse

Prolapse Promazine
Displacement of an organ or structure from its A phenothiazine drug used to tranquillise dis-
normal position. The term is applied chiefly to turbed patients (see NEUROLEPTICS).
downward displacements of the RECTUM and
UTERUS. Promethazine Hydrochloride
A widely used antihistamine drug with a pro-
Prolapsed Intervertebral Disc longed action and a pronounced sedative effect.
The SPINAL COLUMN is built up of a series of (See ANTIHISTAMINE DRUGS.)
bones, known as vertebrae, placed one upon
the other. Between these vertebrae lies a series Promethazine Theoclate
of thick discs of fibro-cartilage known as A drug that is widely used in the alleviation or
intervertebral discs. Each disc consists of an prevention of sea-sickness (see MOTION
outer portion known as the anulus fibrosus, (TRAVEL) SICKNESS).
and an inner core known as the nucleus pul-
posus. The function of these discs is to give Pronation
flexibility and resiliency to the spinal column The movement whereby the bones of the fore-
and to act as buffers against undue jarring. In arm are crossed and the palm of the hand faces
other words, they are most efficient shock- downwards.
absorbers. They may, however, PROLAPSE, or
protrude, between the two adjacent vertebrae. Prone
If this should happen they press on the neigh- Lying with the face down, or positioning the
bouring spinal nerve and cause pain. As the arm and hand so that the palm faces
most common sites of protrusion are between downwards.
the last two lumbar vertebrae and between the
last lumbar vertebra and the sacrum, this Prophylaxis
means that the pain occurs in the back, caus- Treatment or action adopted with the view of
ing LUMBAGO, or down the course of the sci- warding off disease.
atic nerve causing SCIATICA. The prolapse is
most likely to occur in middle age, which Propofol
suggests that it may be associated with A drug used intravenously to induce general
degeneration of the disc involved, but it can ANAESTHESIA. Propofol may be used by intra-
occur in early adult life as well. It usually venous infusion to maintain anaesthesia; it is
occurs when the individual is performing also useful for sedating patients in intensive
some form of exercise which involves bending care.
P or twisting, as in gardening. The onset of pain
may be acute and sudden, or gradual and Propranolol Hydrochloride
more chronic in intensity. (See also INTER- One of the BETA-ADRENOCEPTOR-BLOCKING
VERTEBRAL DISC.) DRUGS, propranolol hydrochloride is used in
the treatment of ANGINA PECTORIS, myo-
Treatment varies, depending (amongst cardial infarction (see under HEART, DISEASES
other things) on the severity of the condition. OF), certain abnormal rhythms of the heart,
In the acute phase, rest in bed is advisable, and high blood pressure (HYPERTENSION). It
along with ANALGESICS. Later, exercise and also prevents attacks of MIGRAINE, and is used
physiotherapy are helpful, and in some cases for certain anxiety states particularly those
manipulation of the spine brings relief by associated with unpleasant bodily sensations,
allowing the herniated, or prolapsed, disc to such as palpitations. (See also ADRENERGIC
slip back into position. The injection of a RECEPTORS.)
local anaesthetic into the spine (epidural
ANAESTHESIA) is yet another measure that Proprietary Name
often helps the more chronic cases. If those The trade name of a drug registered by the
measures fail, surgery to remove the prolapsed pharmaceutical company which has developed
disc may be necessary, but the patients condi- and patented it. This protects the name,
tion should be carefully reviewed before ingredients and manufacturing technique for a
surgery is considered since success is not cer- set period of time, and helps the company to
tain. An alternative form of treatment is the recoup the often costly research and develop-
injection into the disc of chymopapain, an ment needed to produce and test the drug.
ENZYME obtained from the paw-paw, which Doctors may prescribe a drug by its trade name
dissolves the disc. or by its official, approved name, although the
 Prostate Gland 585

NHS encourages the latter. (See GENERIC DRUG; thought to arise in the PROSTATE GLAND, are a
PATENT.) group of fatty-acid substances with a wide range
of activity. The richest known source is semen,
Proprioceptors but they are also present in many other parts of
Sensory nerve endings in the muscles, tendons the body. Their precise mode of action is not
and joints which signal to the brain their pos- yet clear, but they are potent stimulators of
ition relative to the outside world and the state muscle contraction and they are also potent
of contraction of the muscle. During move- VASODILATORS. They cause contraction of the
ment, a regular flow of information to the brain UTERUS and have been used to induce labour
from the proprioceptors, the eyes and ears (see PREGNANCY AND LABOUR); they are also
ensures that actions are coordinated and the being used as a means of inducing therapeutic
bodys balance maintained. abortions (see ABORTION).
Prostaglandins play an important part in the
Proptometer production of PAIN, and it is now known that
See EXOPHTHALMOMETER. ASPIRIN relieves pain by virtue of the fact that it
prevents, or antagonises, the formation of cer-
Proptosis tain prostaglandins. In addition, they play
A condition in which the EYE protrudes from some, although as yet incompletely defined,
the orbit. Some causes include thyroid disorders part in producing inflammatory changes. (See
(see THYROID GLAND, DISEASES OF), tumours INFLAMMATION; NON-STEROIDAL ANTI-
within the orbit, inflammation or infection of INFLAMMATORY DRUGS (NSAIDS).)
the orbit. Proptosis due to endocrine abnormal- Thus prostaglandins have potent biological
ity (e.g. thyroid problems) is known as effects, but their instability and rapid metabol-
EXOPHTHALMOS. ism make them short-acting. They are pro-
duced but not stored by most living cells and
Propylthiouracil act locally. The two most important prosta-
An oral antithyroid drug given daily to a person glandins are prostacycline and thromboxane:
with HYPERTHYROIDISM. It interferes with the prostacycline is a vasodilator and an inhibitor of
bodys production of thyroid hormones. platelet aggregation; thromboxanes have the
opposite effects and cause vasoconstriction and
Prospective Study platelet aggregation. The NSAIDs act by block-
Research in which patients are studied from the ing an ENZYME called cyclo-oxygenase which
first contact with a doctor or hospital regarding converts arachidonic acid to the precursors of
their illness as opposed to a retrospective the various prostaglandins. Despite their potent
study, in which notes are obtained of a group of pharmacological properties, the role of prosta- P
patients already treated or under treatment. glandins in current therapeutics is limited and
The advantage is that before the study is under- controversial. They have been used most suc-
taken, decisions can be made on what criteria cessfully as an inhibitor of platelet aggregation
determine who should enter the study, what in extra-corporeal haemoperfusion systems.
information to collect and how many patients The problems with the prostacyclines is that
are needed to provide a meaningful result. The they have to be given intravenously as they are
results of prospective studies are regarded as inactive by mouth, and continuous infusion is
likely to be far more accurate than those from required because the drug is rapidly eliminated
retrospective studies, where missing data and with a half-life of minutes. Side-effects tend to
both reearcher and patient bias can colour the be severe because the drug is usually given at the
results. highest dose the patient can tolerate. The hope
for the future lies in the exploitation of the
Prostacyclin compound to generate, synthetically, stable
A prostaglandin (see PROSTAGLANDINS) pro- orally active prostacycline analogues which will
duced by the endothelial lining of the blood inhibit platelet aggregation and hence throm-
vessels. It inhibits the aggregation of PLATELETS, botic events, and yet have minimal effects on
and thereby reduces the likelihood of the blood the heart and blood vessels.
clotting. It is also a strong vasodilator (see
VASODILATORS). Prostate Gland
This is an accessory sex gland in males which is
Prostaglandins wrapped round the URETHRA as this tube
Those natural substances, so-called because leaves the URINARY BLADDER. Opening into
they were first discovered in the SEMEN and the urethra, the gland secretes an alkaline fluid
 586 Prostate Gland, Diseases of

during ejaculation and is a constituent of Little is known about the cause, but the major-
SEMEN. The gland grows during adolescence ity of prostate cancers require the male hor-
and is sensitive to the concentrations of sex mones, androgens, to grow.
hormones.
Symptoms These are similar to those result-
Prostate Gland, Diseases of ing from benign prostatic hypertrophy (see
Disease of the PROSTATE GLAND can affect the above).Spread of the cancer to bones can cause
flow of URINE so that patients present with uro- pain. The use of a blood test measuring the
logical symptoms. amount of an ANTIGEN, PROSTATE SPECIFIC
ANTIGEN (PSA), can be helpful in making the
Prostatitis This can be either acute or diagnosis as can an ULTRASOUND scan of the
chronic. Acute prostatitis is caused by a bac- prostate.
terial infection, while chronic prostatitis may
follow on from an acute attack, arise insidi- Treatment This could be surgical, with
ously, or be non-bacterial in origin. removal of the prostate (either via an abdominal
incision, total prostatectomy, or trans-
Symptoms Typically the patient has pain in urethrally), or could be by radiotherapy. In
the PERINEUM, groins, or supra pubic region, more advanced cancers, treatment with anti-
and pain on EJACULATION. He may also have androgen drugs, such as cyprotexone acetate or
urinary frequency, and urgency. certain oestrogens, is used to inhibit the growth
of the cancer.
Treatment Acute and chronic prostatitis are
treated with a prolonged course of antibiotics. Prostate Specific Antigen (PSA)
Patients with chronic prostatitis may also An ENZYME produced by glandular tissue in the
require anti-inflammatory drugs, and PROSTATE GLAND. When the gland enlarges (see
antidepressants. PROSTATE, DISEASES OF), greater amounts of
PSA are secreted, raising the concentration of
Prostatic enlargement This is the result the enzyme in the blood. This is especially so in
of benign prostatic hyperplasia (BPH), causing cancer of the prostate, and testing the level of
enlargement of the prostate. The exact cause of PSA is an indicator that the disease may be
this enlargement is unknown, but it affects 50 present. There is much controversy about the
per cent of men between 40 and 59 years and use of PSA as a screening test. Its proponents
95 per cent of men over 70 years. claim that its use reduces deaths from prostate
cancer; its opponents suggest that it does this
P Symptoms These are urinary hesitancy, poor only by bringing to light many cases that
urinary stream, terminal dribbling, frequency needed no treatment and would not have
and urgency of urination and the need to pass caused death in any case. Further, if the level of
urine at night (nocturia). The diagnosis is made PSA is very high, the disease is already
from the patients history; a digital examination advanced; where the result is equivocal it is
of the prostate gland via the rectum to assess uncertain whether the benefits of treatment
enlargement; and analysis of the urinary flow outweigh the risks.
rate.
Prostatectomy
Treatment This can be with tablets, which An operation to remove part or all of the PRO-
either shrink the prostate an anti-androgen STATE GLAND. The most common method is
drug such as finasteride or relax the urinary transurethral prostatectomy (TURP) carried
sphincter muscle during urination. For more out during cytoscopy. A very enlarged prostate
severe symptoms the prostate can be removed may need to be removed by a retropubic prosta-
surgically, by transurethral resection of prostate tectomy. After several weeks, most patients are
(TURP), using either electrocautery or laser able to resume normal activity including sexual
energy. A new treatment is the use of micro- intercourse.
waves to heat up and shrink the enlarged gland.
Prostatis
Cancer Cancer of the prostate is the fourth See under PROSTATE GLAND, DISEASES OF.
most common cause of death from cancer in
northern European males: more than 10,000 Prostatism
cases are diagnosed every year in the UK and The condition induced by benign enlargement
the incidence is rising by 3 per cent annually. of the PROSTATE GLAND.
 Prosthesis 587

Prosthesis is the replacement of the part of a tooth which

An artificial replacement of a missing or mal- sticks through the gum. It is fixed to the
functioning body part. Examples include false remaining part of the tooth and may be made
legs or arms fitted after AMPUTATION (see of metal, porcelain, plastic or a combination of
below); artificial heart valves; artificial heart these. A bridge is the replacement of two or
devices; COCHLEAR IMPLANTS to improve hear- three missing teeth and is usually fixed in place.
ing; a bio-artificial PANCREAS (containing live The replacement teeth are held in position by
pancreatic cells from pigs) now under develop- being joined to one or more crowns on the
ment to treat DIABETES MELLITUS; artificial adjacent teeth. A denture is a removable pros-
bone; and (under development) artifical lungs. thesis used to replace some or all the teeth. The
Cosmetic prostheses such as artifical eyes, teeth, teeth are made of plastic or porcelain and the
noses and breasts are in widespread use. base may be of plastic or metal. Removable
Development of such mechanical and bio- teeth may be held more firmly by means of
mechanical devices points the way to a much implants.
wider use of effective prostheses, enabling
people who would previously have died or been Heart The surgical replacement of stenosed
severely handicapped to lead normal or near or malfunctioning heart-valves with metal or
normal lives. The technical hazards that have plastic, human or pig valves has been routinely
already been overcome provide a sound founda- carried out for many years. So too has been the
tion for future successes. Progress so far in pro- insertion into patients with abnormal heart
ducing prostheses should also ensure that organ rhythms of battery-driven artificial pacemakers
replacement is free from the serious ethical (see CARDIAC PACEMAKER) to restore normal
problems that surround the use of genetic function. The replacement of a faulty heart
manipulation to cure or prevent serious diseases with an artificial one is altogether more chal-
(see ETHICS). lenging. The first working attempt to create an
artificial heart took place in the early 1980s.
Limbs These are best made to meet the indi- Called the Jarvik-7, it had serious drawbacks:
viduals requirements but can be obtained off patients had to be permanently connected to
the shelf . Artificial joints normally comprise apparatus the size of an anaesthetic trolley; and
complex mechanisms to stimulate flexion and it caused deaths from infection and clotting of
rotation movements. Leg prostheses are gener- the blood. As a result, artificial hearts have been
ally more useful than those for arms, because used primarily as bridging devices to keep
leg movements are easier to duplicate than patients alive until a suitable donor heart for
those of the arm. Modern electronic circuitry transplantation can be found. Recent work in
that enables nerve impulses to be picked up and North America, however, is developing artificial P
converted into appropriate movements is hearts made of titanium and dacron. One type
greatly improving the effectiveness of limb is planted into the chest cavity next to the
prostheses. patients own heart to assist it in its vital func-
tion of pumping blood around the body.
Eyes Artificial eyes are worn both for appear- Another replaces the heart completely. Eventu-
ance and for psychological reasons. They are ally, it is probable that artificial hearts will
made of glass or plastic, and are thin shells of a replace heart transplants as the treatment of
boat-shape, representing the front half of the choice in patients with serious heart disorders.
eye which has been removed. The stump
which is left has still the eye-muscles in it, and Liver Artificial livers work in a similar way to
so the artificial eye still has the power of mov- kidney dialysis machines (see DIALYSIS). Blood is
ing with the other. A glass eye has to be removed from the body and passed through a
replaced by a new one every year. Plastic eyes machine where it is cleaned and treated and
have the advantage of being more comfortable then returned to the patient. The core of the
to wear, being more durable, and being device comprises several thousand flexible
unbreakable. Research is taking place aimed at membrane tubules on which live liver cells
creating a silicon chip that stimulates the visual (from pigs or people) have been cultured. There
cortex and thus helps to restore sight to the is an exchange of biological molecules and
blind. water with the circulating blood, and the
membrane also screens the foreign cells from
Dental prostheses is any artificial the patients immune system, thus preventing
replacement of a tooth. There are three main any antagonistic immune reaction in the
types: a crown, a bridge and a denture. A crown recipient.
 588 Protease

Nose The making of a new nose is the oldest ALBUMINS, are present in the URINE. It is often a
known operation in plastic surgery, Hindu symptom of serious heart or kidney disease,
records of such operations dating back to 1,000 although some normal people have mild and
BC. Loss of a nose may be due to eroding dis- transient proteinuria after exercise.
ease, war wounds, gun-shot wounds or dog
bites. In essence the operation is the same as Causes
that practised a thousand years before Christ: KIDNEY DISEASE is the most important cause
namely the use of a skin graft, brought down of proteinuria, and in some cases the discovery
from the forehead. Alternative sources of the of proteinuria may be the first evidence of
skin graft today are skin from the arm, chest or such disease. This is why an examination of
abdomen. As a means of support, the new nose the urine for the presence of albumin consti-
is built round a graft of bone or of cartilage tutes an essential part of every medical exam-
from the ear. ination. Almost any form of kidney disease
will cause proteinuria, but the most frequent
Protease form to do this is glomerulonephritis (see under
A digestive ENZYME also known as a proteo- KIDNEYS, DISEASES OF). In the subacute (or
lytic enzyme that breaks down PROTEIN in nephrotic) stage of glomerulonephritis, the
food as part of the digestive process. The com- most marked proteinuria of all may be found.
plex protein molecules are reduced to their con- Proteinuria is also found in infections of the
stituent AMINO ACIDS. kidney (pyelitis) as well as in infections of the
bladder (cystitis) and of the urethra
Protease Inhibitors (urethritis).
A new group of drugs which, in combination PREGNANCY The development of proteinuria
with antiviral agents, are used to treat AIDS (see in pregnancy requires investigation, as it may be
AIDS/HIV). They inhibit the activity of PROTE- the first sign of one of the most dangerous
ASE, an enzyme produced by HIV, and which complications of pregnancy: toxaemia of preg-
breaks down proteins. The drugs have recently nancy (PRE-ECLAMPSIA and ECLAMPSIA) and
been introduced: those in use are indinavir, glomerulonephritis. Proteinuria may also result
nelfinavir, ritonavir and saquinavir. from the contamination of urine with vaginal
secretions. (See also PREGNANCY AND LABOUR.)
Protein CARDIOVASCULAR DISORDERS are commonly
The term applies to members of a group of accompanied by proteinuria, particularly when
non-crystallisable nitrogenous substances the right side of the heart is failing. In severe
widely distributed in the animal and vegetable cases of failure, accompanied by OEDEMA, the
P kingdoms, and forming the characteristic proteinuria may be marked. (See also HEART, DIS-
materials of their tissues and fluids. They are EASES OF.)
essentially combinations of AMINO ACIDS. They FEVER often causes proteinuria, even though
mostly dissolve in water and are coagulated by there is no actual kidney disease. The proteinu-
heat and various chemical substances. Typical ria disappears soon after the temperature
examples of protein substances are white of egg becomes normal. (See also PYREXIA.)
and gelatin. DRUGS AND POISONS These include arsenic,
Proteins constitute an essential part of the lead, mercury, gold, copaiba, salicylic acid and
diet as a source of energy, and for the replace- quinine.
ment of protein lost in the wear and tear of ANAEMIA A trace of albumin may be found in
daily life. Their essential constituent from this the urine in severe anaemia.
point of view is the nitrogen which they con- POSTURAL OR ORTHOSTATIC ALBUMINURIA
tain. To be absorbed, or digested, proteins have This type is important because, if its true cause
to be broken down into their constituent amino is unrecognised, it may be taken as a sign of
acids. The adult human body can maintain kidney disease. The significance of postural pro-
nitrogenous equilibrium on a mixture of eight teinuria is unclear: it is more common among
amino acids, which are therefore known as the young people and is absent when the person is
essential (or indispensable) amino acids. They recumbent hence the importance of testing a
are isoleucine, leucine, lysine, methionine, urine sample that is taken before rising in the
phenylalanine, threonine, tryptophan and val- morning.
ine. In addition, infants require histidine.
Treatment The treatment is that of the
Proteinuria underlying disease. (See KIDNEYS, DISEASES
A condition in which proteins, principally OF.)
 Pseudocyst 589

Proteolysis Proximal
The mechanism by which complex PROTEIN A term of comparison applied to structures
molecules are broken down by digestive which are nearer the centre of the body or the
enzymes (see PROTEASE) in the stomach and median line as opposed to more distal, or
small intestine. The constituent AMINO ACIDS distant, structures.
are then absorbed into the bloodstream.
Prozac
Prothrombin See FLUOXETINE.
An inactive substance in the blood PLASMA that
is the precursor of the ENZYME, thrombin, Prurigo
which clots the blood. The conversion occurs An intensely itching form of eczema (see
when a blood vessel is damaged and the process DERMATITIS) in which LICHEN takes a nodular
of blood COAGULATION occurs. form.

Proton Pump Pruritus

A key enzyme system in the parietal cells of the Another name for itching, it is a common
mucosal lining of the stomach: hydrogen ions symptom with many causes. It may accompany
are produced which acidify the stomachs secre- obvious skin disease such as URTICARIA, eczema
tions and convert pepsinogen to PEPSIN, an (see DERMATITIS) or SCABIES. Pruritus may be
active participant in the digestion of food. systemic in origin and can be caused by
advanced hepatic (liver) or renal (kidney) fail-
Proton-Pump Inhibitors ure, uncontrolled DIABETES MELLITUS, or
These are drugs that inhibit the production of HYPERTHYROIDISM. It may be due to drugs and
acid in the stomach by blocking a key enzyme certain forms of malignancy for example,
system, known as the PROTON PUMP, of the par- Hodgkins disease (see LYMPHOMA). Anxiety or
ietal cells of the stomach. The drugs include depression may also cause pruritus. Pruritus
omeprazole, lansoprazole and pantoprazole, ani, itching round the ANUS, is a common
and they are the treatment of choice for troublesome condition: it may be caused by
oesophagitis (erosion and stricture see under obsessive efforts to keep this area clean; soft
OESOPHAGUS, DISEASES OF); for the short-term toilet paper and gentle cleansing once daily
treatment for gastric ulcer (see under STOMACH, should be sufficient. A weak anal sphincter, skin
DISEASES OF) and DUODENAL ULCER; and, in tags, and HAEMORRHOIDS may also cause
combination with ANTIBIOTICS, for the eradica- itching, and these conditions should be treated.
tion of Helicobacter pylori.
Treatment The first aim is to identify and P
Protoplasm treat the cause, whether local or systemic. Once
The viscid, translucent, glue-like material con- the cause has been dealt with, symptomatic
taining fine granules and composed mainly of treatment may be required to break the cycle of
proteins, which makes up the essential material itching, scratching and itching; topical steroid
of plant and animal cells and has the properties ointments and occlusive dressings help to pre-
of life. vent scratching. For dry skin, emollients (see
OINTMENTS) are useful. Local anaesthetics (see
Protozoa under ANAESTHESIA) provide relief but may cause
A simple, primitive animal comprising a single allergic reactions, and systemic ANTIHISTAMINE
cell. Protozoa are microscopic in size but are DRUGS at night can help.
much larger than BACTERIA. Most protozoa live
freely, but around 30 are parasitic in humans Prussic Acid Poisoning
causing disease such as amoebiasis (see DYS- See CYANIDE POISONING.
ENTERY) and GIARDIASIS (intestinal infections),
MALARIA, kala-azar (see LEISHMANIASIS) and Pseudocyesis
SLEEPING SICKNESS. Some protozoa are able to Pseudocyesis means spurious or false pregnancy,
excrete, respire, and absorb food particles and a condition characterised by enlargement of the
they may move around like a mobile jelly or by abdomen, and even enlargement of the breasts
means of flagellae. and early-morning sickness the woman being
quite convinced that she is pregnant.
Protriptyline
One of the tricyclic ANTIDEPRESSANT DRUGS. Pseudocyst
(See MENTAL ILLNESS.) A space within an organ without a defined
 590 Pseudohermaphrodite

lining and which contains fluid. Patients with accomplished by the contraction of this muscle.
chronic pancreatitis (see PANCREAS, DISORDERS Disease of the spine in the lumbar region may
OF) sometimes develop these pseudocysts which produce an ABSCESS which lies within the
fill with pancreatic juice containing enzymes sheath of this muscle and makes its way down
produced by the gland. Abdominal pain usually to the front of the thigh. Such an abscess is
results; treatment is by surgical draining. known as a psoas abscess.

Pseudohermaphrodite Psoralens
A person in whom the gonads (testes or ovaries See PHOTOCHEMOTHERAPY; PHOTODERMA-
see GONAD) of only one sex are present in the TOSES.
body but in whom the external GENITALIA may
not be obviously male or female. The condition Psoriasis
is a result of a hormonal imbalance and can This chronic, relapsing inflammatory skin dis-
normally be treated by appropriate surgery and ease is extremely common, affecting about 2 per
hormone drugs. (See also HERMAPHRODITE.) cent of the UK population. Frequently it is
mild and trivial, affecting only the points of the
Pseudohypertrophic Muscular elbows or knees and the scalp, but in a substan-
Dystrophy tial minority of sufferers the disease is much
A condition in which certain muscles enlarge more widespread and causes considerable dis-
owing to a fatty and fibrous degeneration, giv- comfort and social embarrassment. Rarely, it
ing a false appearance of increased strength. can be universal and even life-threatening.
The predisposition to psoriasis is genetic,
Pseudomonas Aeruginosa multiple genes being involved, but postnatal
A pathogenic bacterium of the genus pseu- factors such as acute infection, hormonal dis-
domonas rod-like, motile gram-negative bac- turbance, pregnancy and drugs can influence or
teria (see GRAMS STAIN) that occurs in pus provoke it. The sexes are equally affected and
from wounds and is associated with urinary onset is most common in the second or third
tract infections. The bacteria mostly live in soil decade of life.
and decomposing organic matter and help to The psoriatic lesion is dull red, scaly and well
recycle nitrogen in nature. Most of the bacteria defined. Scale is shed constantly, either in tiny
in this genus are harmless to humans. pieces or as large plaques. The scalp is usually
affected but the disease does not cause signifi-
Pseudoxanthoma Elasticum cant hair loss. The fingernails may be pitted or
This is a hereditary disorder of elastic tissue. ridged and the toenails grossly thickened. Sev-
P Degenerating elastic tissue in the skin produces eral clinical patterns occur: in guttate psoriasis,
lesions which look like soft yellow papules. a sudden explosion of multiple tiny lesions may
Elastic tissue in the eye and blood vessels is also follow a streptococcal throat infection, espe-
involved, giving rise to visual impairment, cially in children. Larger lesions are character-
raised blood pressure and haemorrhages. istic of discoid (plaque) psoriasis, the usual
adult form. In the elderly the plaques may be
Psittacosis mainly in the large body folds flexural
Also called parrot disease. An infectious disease psoriasis. Rarely, psoriasis may be universal
of parrots and other exotic birds which may be (psoriatic erythroderma), or a sterile pustular
transmitted to humans and is caused by the eruption may supervene (pustular psoriasis).
micro-organism Chlamydia psittaci. It presents Mucous membranes in the mouth and else-
as PNEUMONIA or a systemic illness in which the where are not affected. Psoriasis does not affect
patient has an enlarged spleen and liver and internal organs, but in about 1 per cent of sub-
PNEUMONITIS. Tetracycline is an effective jects an inflammatory joint disease (psoriatic
treatment, but relapses may occur. arthritis) may be associated with the condition.

Psoas Treatment There is no absolute cure, but

A powerful muscle which arises from the front several agents used topically are of value includ-
of the vertebral column in the lumbar region, ing coal-tar extracts, DITHRANOL, CORTICO-
and passes down, round the pelvis and through STEROIDS and synthetic derivatives of vitamins
the groin, to be attached to the inner side of the A and D. Ultraviolet B phototherapy (and
thigh-bone not far from its upper end. The act natural sunlight) benefits most but not all
of sitting up from a recumbent posture, or that psoriatics. Systemic therapy, including PHOTO-
of bending the thigh on the abdomen, is mainly CHEMOTHERAPY, is reserved for severe forms of
 Psychologist 591

psoriasis. METHOTREXATE, CICLOSPORIN A and Psychogeriatrics

oral RETINOIDS are the most effective drugs, but The branch of PSYCHIATRY that investigates,
they are potentially dangerous and require diagnoses and treats the mental-health prob-
expert monitoring. lems of old people. Psychogeriatricians work in
Patient information may be obtained close co-operation with physicians for the care
through the Psoriasis Association. of the elderly, and with other health profes-
sionals and social workers in this branch of
Psyche medicine.
The mind or soul of an individual and his or
her mental in contrast to the physical Psychologist
functioning. Psychologists have a graduate degree in PSYCH-
OLOGY, followed by an accredited postgraduate
Psychedelic Drugs training leading to chartered status. There are a
Drugs, such as CANNABIS and LYSERGIC ACID number of different branches related to the
DIETHYLAMIDE (LSD), that expand conscious- various applications psychology has to different
ness and perception. (See DEPENDENCE.) fields of work.

Psychiatry Types of psychologist

That branch of medical science which treats EDUCATIONAL PSYCHOLOGISTS Working in
mental disorder and disease and also helps with schools and in local education authorities, they
the management of people with learning dis- are concerned with childrens learning and
abilities (see LEARNING DISABILITY; MENTAL development. They carry out tasks aimed at
ILLNESS). improving childrens learning and helping
teachers to become more aware of social factors
Psychoanalysis that affect teaching and learning. Chartered
The term applied to the theories and practice of educational psychlogists have a graduate degree
the school of psychology originating with Freud in psychology and also a teaching qualification,
and developed by Jung and other psychothera- with experience; in addition they have com-
pists (see PSYCHOLOGY). It depends upon the pleted a one-year postgraduate course in edu-
theory that states of disordered mental health cational psychology with supervised experience.
have been produced by a repression in the sub- COUNSELLING PSYCHOLOGISTS apply psych-
conscious of painful memories or of conflicting ology to working in collaboration with people
instincts, thus absorbing the individuals men- across a range of human problems. For example,
tal energy and diverting attention from normal helping people to manage difficult life events,
mental activities. relationship issues, BEREAVEMENT and issues P
Psychoanalysis aims at discovering these raised by mental-health problems. Their usual
repressed memories, which are responsible for route to qualify is completing a three-year post-
the diversion of mental power and of which the graduate training in counselling psychotherapy.
affected person usually is only dimly aware or CLINICAL PSYCHOLOGISTS have completed a
quite unaware. The fundamental method of three-year doctorate training course as well as
psychoanalytical treatment is the free expression having their first degree in psychology. They
of thoughts, ideas and fantasies on the part of work in health and care settings. Their aim is to
the patient. To facilitate this, the analyst uses reduce psychological distress and to promote
techniques to relax the patient and maintains a psychological well-being. They work with indi-
neutral attitude to his or her problems. In the viduals, families, groups and organisations: the
course of analysis the patient will re-explore individuals are people who have problems such
his or her early emotional attitudes and as anxiety, DEPRESSION, serious and enduring
tensions. MENTAL ILLNESS, brain injuries, addiction,
The fundamental conception of psycho- child and family problems, LEARNING DIS-
analysis, although hard to prove by orthodox ABILITY and the after-effects of trauma. They
scientific methods and therefore challenged by provide various types of treatment, for example
some psychiatrists, has been widely adopted COGNITIVE BEHAVIOUR THERAPY and family
and developed by other schools of psychology. therapy, based on psychological theories and
Freuds work changed the attitudes of the scien- research. They also carry out research, training,
tific community and the public to the problems consultation with other professionals involved
of the neurotic, the morbidly anxious, the with clients, and supervision of colleagues.
fearful and to the mental and emotional (See also NEUROSIS; PSYCHOTHERAPY.)
develoment of the child. FORENSIC PSYCHOLOGISTS work in the
 592 Psychology

criminal and justice fields, applying psycho- sequences. (3) A failure to learn by experience
logical theory to aspects of legal processes in and to be deterred from crime by punishment.
courts, criminal investigation, and understand- (4) Absence of any other form of mental
ing and treating psychological problems associ- disorder that would explain the unusual
ated with criminal behaviour. They will have behaviour. The corresponding American ter-
completed an accredited training course in minology is antisocial personality disorder.
forensic psychology. (See MENTAL ILLNESS.)
HEALTH PSYCHOLOGISTS apply psychological
methods to studying behaviour relevant to Psychosexual
health, illness and care including health promo- Relating to the relationships between the
tion and education. behavioural, emotional, mental and
OCCUPATIONAL PSYCHOLOGISTS are concerned physiological characteristics of sex or sexual
with how people perform at work and how development.
organisations function. They work in manage-
ment, personnel, selection and careers advice. Psychosis
They have a postgraduate degee in occupational One of a group of mental disorders in which
psychology and will have had to undertake the affected person loses contact with reality.
three years supervised practice. Thought processes are so disturbed that the per-
son does not always realise that he or she is ill.
Psychology Symptoms include DELUSIONS, HALLUCIN-
The scientific study of people: how they think, ATIONS, loss of emotion, MANIA, DEPRESSION,
and how and why they act, react and interact as poverty of thought and seriously abnormal
they do. It covers such matters as memory, behaviour. Psychoses include SCHIZOPHRENIA,
rational and irrational thought, intelligence, MANIC DEPRESSION and organically based
learning, personality, perceptions and emo- mental disorders. (See also MENTAL ILLNESS.)
tions. There are different schools of psychology,
varying both in attitude and in methods of Psychosomatic Diseases
working. The main groups consist of the intro- Taken at face value, the term psychosomatic
spectionist Freudian, Jungian and Adlerian simply means the interaction of psyche (mind)
schools, and the gestaltist, behaviourist and and soma (body). As such it is a non-
cognitive schools. Although many practical controversial concept that points out the many
psychologists deny belonging to any specific ways in which psychological factors affect the
school, contemporary psychology in general expression of physical disorder and vice-versa.
favours the cognitive schools, although many Few doubt that stress makes many physical ill-
P are sub-specialities based on practical consider- nesses worse, at least as far as symptoms are
ations. (See also FREUDIAN THEORY; JUNGIAN concerned. There are also few physical illnesses
ANALYSIS; ADLER; GESTALTISM; PSYCHOLOGIST.) in which the outcome is not made worse by
psychological factors: depression after a heart
Psychometrics attack, for example, has a worse effect on prog-
The use of standardised psychological tests to nosis than even smoking. A little more prob-
measure differences in functions for example, lematic is the very popular belief that stress
intelligence and personality in individuals. causes relapses of physical disorders, such as
cancer; some studies have found this to be the
Psychoneurosis case, others not.
A general term applied to various functional However, calling a condition psychosomatic
disorders of the nervous system. (See NEUROSIS.) implies something more the primacy of the
psyche over the soma. Going back to the
Psychopathic influential theories and practice of PSYCHO-
Psychopathic disorder is defined by the Mental ANALYSIS as expounded from the 1930s, many
Health Act 1983 as a persistent disorder or dis- diseases have been proposed as the result of psy-
ability of mind (whether or not including sig- chological factors.These have included PEPTIC
nificant impairment of intelligence) which ULCER, ULCERATIVE COLITIS, ASTHMA, PSOR-
results in abnormally aggressive or seriously IASIS and others. In this view, much physical
irresponsible conduct. The cardinal features are disorder is due to repressed or excessive emo-
as follows: (1) Absence of normal feelings for tions. Likewise it is also argued that whereas
other people such as love, affection, sympathy some people express psychological distress via
and condolence. (2) A tendency to antisocial psychological symptoms (such as anxiety,
impulsive acts with no forethought of the con- depression and so on), others develop physical
 Psychotherapy 593

symptoms instead and that they are also at chronically incapacitated, especially where there
greater risk of physical disease. is a high suicide risk. Patients are only con-
The trouble with this view is that medical sidered for psychosurgery when they have failed
advances repeatedly show that it goes too far. to respond to routine therapies. One contra-
Stress certainly causes physical symptoms for indication is marked histrionic or antisocial
example, DYSPEPSIA but the belief that it personality. The conditions in which a favour-
caused peptic ulcers vanished with the discovery able response has been obtained are intractable
of the true cause: colonisation of the stomach and chronic obsessional neuroses (see NEUR-
by the bacterium, Helicobacter pylori. Of course, OSIS), anxiety states and severe chronic
stress and social adversity affect the risk of many DEPRESSION.
diseases. For example, the incidence of heart Psychosurgery is now rare in Britain. The
disease among UK government employees (civil Mental Health Act 1983 requires not only con-
servants) has been shown to be influenced by sent by the patient confirmed by an
their social class and their degree of job satisfac- independent doctor, and two other representa-
tion. But we do not know how this works. tives of the Mental Health Act Commission
Some argue that social adversity and stress but also that the Commissions appointed med-
influence how the heart functions (He died of a ical representative also advise on the likelihood
broken heart). Stress can also affect IMMUNITY of the treatment alleviating or preventing a
but it cannot cause AIDS/HIV and we do not deterioration in the patients condition.
know if there is a link running from stress to
abnormal immune function to actual illness. Psychotherapy
We can say that psychological factors pro- A psychological rather than physical method for
voke physical symptoms, and often even the treatment of psychological and psychiatric
explain how this can happen. For example, disorders (see PSYCHOLOGY; PSYCHIATRY).
when you are anxious you produce more epi- Almost every type of disease or injury has a
nephrine (adrenaline), which gives rise to chest mental aspect, even if this relates only to the
pain, butterflies in the stomach and PALPITA- pain or discomfort that it causes. In some dis-
TION. These symptoms are not all in the eases, and with some temperaments, the mental
mind, even if the trigger is a psychological one. factor is much more pronounced than in
People who are depressed are more likely to others; for such cases psychotherapy is particu-
experience nearly every physical symptom there larly important. The chief methods employed
is, but especially pain and fatigue. Taken as a all depend on the client-therapist relationship
whole, psychologically induced symptoms are being of prime importance.
an enormous burden on the NHS and probably
responsible for more doctor visits and sickness Suggestion is a commonly employed P
absence than any other single cause. Also we method, used in almost every department of
can be confident that social adversity and stress medicine. It may consist, in its simplest form,
powerfully influence the outcome of many ill- merely of emphasising that the patients health
nesses; likewise, a vast range of unhealthy activ- is better, so that this idea becomes fixed in the
ities and behaviours such as smoking, excessive patients mind. A suggestion of efficacy may be
alcohol intake, excessive eating, and so on. But conveyed by the physical properties of a medi-
we must be careful not to assume that our emo- cine or by the appearance of some apparatus
tions directly cause our illnesses. used in treatment. Again, suggestion may be
conveyed emotionally, as in religious healing.
Psychosurgery Sometimes a therapeutic suggestion may be
This was introduced in 1936 by Egas Moniz, made to the patient in a hypnotic state (see
Professor of Medicine in Lisbon University, for HYPNOTISM).
the surgical treatment of certain psychoses (see
PSYCHOSIS). For his work in this field he shared Analysis consists in the elucidation of the
the Nobel prize in 1949. The original oper- half-conscious or subconscious repressed mem-
ation, known as leucotomy, consisted of cutting ories or instincts that are responsible for some
white fibres in the frontal lobe of the BRAIN. It cases of mental disorder or personal conflicts.
was accompanied by certain hazards such as
persistent EPILEPSY and undesirable changes in Group therapy is a method whereby
personality; pre-frontal leucotomy is now patients are treated in small groups and encour-
regarded as obsolete. Modern stereotactic sur- aged to participate actively in the discussion
gery may be indicated in certain intractable which ensues amongst themselves and the par-
psychiatric illnesses in which the patient is ticipating therapists. A modification of group
 594 Psychotic

therapy is drama therapy. Large group therapy laterally. The overgrowths look like wings. They
also exists. are commonly seen in people who live in areas
of bright sunlight, particularly when reflected
Education and employment may be from deserts or snowfields. Treatment involves
important factors in rehabilitative excision of the overgrowth. (See also EYE, DIS-
psychotherapy. ORDERS OF.)

Supportive therapy consists of sympa- Ptosis

thetically reviewing the patients situation with See EYE, DISORDERS OF.
him or her, and encouraging the patient to
identify and solve problems. Ptyalin
The name of the ENZYME contained in the SAL-
Short-term supportive psychotherapy IVA, by which starchy materials are changed into
is aimed at stabilising and strengthening the sugar, and so prepared for absorption. It is iden-
psychological defence mechanisms of those tical to the AMYLASE of pancreatic juice. (See
patients who are confronted by a crisis which DIGESTION; PANCREAS.)
threatens to overwhelm their ability to cope, or
who are struggling with the aftermath of major Puberty
life events. The change that takes place when childhood
passes into manhood or womanhood. This
Long-term supportive psychotherapy change is generally a very definite one, occur-
is needed for patients with personality dis- ring at about the age of 14 years, although it is
orders or recurrent psychotic states, where the modified by race, climate, and bodily health so
aim of treatment is to prevent deterioration and that it may appear a year or two earlier or sev-
help the patient to achieve an optimal adapta- eral years later. At this time, the sexual func-
tion, making the most of his or her psycho- tions attain their full development; the contour
logical assets. Such patients may find more of the body changes from a childish to a more
profound and unstructured forms of therapy rounded womanly, or sturdy manly, form; and
distressing. great changes take place in the mode of thought
and feeling.
Behavioural therapy and cognitive In girls, puberty is marked by the onset of
therapy, often carried out by psychologists, MENSTRUATION and development of the
attempt to clarify with the patient specific fea- BREASTS. The latter is usually the first sign of
tures of behaviour or mental outlook respect- puberty to appear, and may occur from nine
P ively, and to identify step-by-step methods that years onwards; most girls show signs of breast
the patient can use for controlling the disorder. development by the age of 13. The time from
Behaviour therapy is commonly used for the beginning of breast development to the
AGORAPHOBIA and other phobias, and cognitive onset of menstruation is usually around two
therapy has been used for depression and anx- years but may range from six months to five
iety. (See MENTAL ILLNESS.) years. The first sign of puberty in boys is an
increase in testicular and penile size (see TES-
Psychotic TICLE; PENIS) between the age of ten and 14.
Adjective describing PSYCHOSIS or noun refer- The LARYNX enlarges in boys, so that the voice
ring to someone with a psychosis. after going through a period of breaking
finally assumes the deep manly pitch. Hair
Psychotropic appears on the pubis and later in the armpits in
Affecting the mind. Psychotropic drugs include both boys and girls, whilst in the former it also
HALLUCINOGENS, HYPNOTICS or sleeping begins to grow on the upper lip, and skin erup-
drugs, sedatives, TRANQUILLISERS and NEURO- tions are not uncommon on the face (see ACNE).
LEPTICS (antipsychotic drugs). The period is one of transition from a phys-
ical and mental point of view. Puberty is not to
PTC be regarded as a physiological coming of age,
See PERCUTANEOUS TRANSHEPATIC CHOLAN- for full development is usually achieved in the
GIOPANCREATOGRAPHY (PTC). early 20s.

Pterygium Pubis
A degenerative disorder of the conjunctiva (see Pubis is the bone that forms the front part of
EYE) which grows over the cornea medially and the pelvis. The pubic bones of opposite sides
 Public Health 595

meet in the symphysis and protect the bladder method of public health. It is defined as the
from the front. study of the distribution and determinants of
health-related states in specified populations,
Public Health and the application of this study to the control
Individuals with health problems go to their of health problems. Public-health practitioners
doctor, are diagnosed and prescribed treatment. also draw on many other skills, such as those of
Public-health doctors use epidemiological stud- statisticians, sociologists, anthropologists,
ies (see EPIDEMIOLOGY, and below) to diagnose economists and policy analysts in identifying
the causes of health problems in populations and trying to resolve the health problems of the
and to plan services to treat the health and dis- societies they serve. Treatments proposed are
ease problems identified. Their concern is often likely to extend well beyond the clinic or hos-
focused particularly on those who are disadvan- pital and may include recommendations for
taged or marginalised, and on the delivery of measures to resolve poverty, improve sanitation
safe, effective and accessible health care: how- or housing, control pollution, change lifestyles
ever, to achieve their goal of better health and such as smoking, improve nutrition, or change
well-being for everybody, they must also influ- health services. At times of acute EPIDEMIC,
ence decision-makers across the whole public-health doctors have considerable legal
community. powers granted to enable them to prevent infec-
Central to an understanding of public health tion from spreading. At other times their work
is recognition that public-health practitioners may be more concerned with monitoring,
are concerned not just with individuals, but also reporting, planning and managing services, and
with whole populations and that improving advocating policy changes to politicians so that
health care plays only a part of public-health health is promoted.
improvement. The health of populations (pub- The term the public health can relate to the
lic health) is also dependent on many factors state of health of the population, and be repre-
such as the social, economic and physical sented by measures such as MORTALITY indices
environment in which the people live and the (e.g. perinatal or infant mortality and standard-
nutrition and health care available to them. ised mortality rates), life expectancy, or meas-
For thousands of years, a fundamental fea- ures of MORBIDITY (illness). These can be
ture of civilisations has been to seek to improve compared across areas and even countries.
the health of the population and protect it from Sometimes people refer to a pubic health-care
disease. This has led to the development of legal system; this is a publicly funded service, the
frameworks which differ widely from country primary aim of which is to improve health by
to country, depending on their social and polit- the use of population-based measures. They
ical development. All are concerned to stop the may include or be separate from private health- P
spread of infectious diseases, and to maintain care services for which individuals pay. The
the safety of urban food and water supplies and structure of these systems varies from country
waste disposal. Most are also associated with to country, reflecting different social com-
housing standards, some form of poverty relief, position and political priorities. There are,
and basic health care. Some trading standards however, some general elements that can be
are often covered, at least in relation to the sale identified:
and distribution of poisons and drugs, and to
controls on industrial and transport safety for Surveillance The collection, collation and
example, in relation to drinking and driving analysis of data to provide useful information
and car design. Although these varied functions about the distribution and causes of health and
protect the public health and were often origin- disease and related factors in populations.
ally developed to improve it, most are man- These activities form the basis of epidemiology,
agerially and professionally separated from which is the diagnostic backbone of public-
todays public-health departments. So public- health practice.
health professionals in the NHS, armed with
evidence of the cause of a disease problem, must Intervention The design, advocacy and
frequently act as advocates for health across implementation of policies to improve health.
many agencies where they play no formal This may be through the provison of PREVENT-
management part. They must also seek to build IVE MEDICINE, environmental measures, influ-
alliances and add a health perspective to the encing the behaviour of individuals, or the
policies of other services wherever possible. provision of appropriate services to limit
disability and handicap. It will lead to advocacy
Epidemiology is the principal diagnostic for health, promoting change in many areas of
 596 Public Health Laboratory Service (PHLS)

policy including, for example, taxation and the 1960s and became more narrowly focused
improved housing and employment within the health-care system and its manage-
opportunities. ment. Increased recognition of the multi-
factorial causes, costs and limitations of
Evaluation Assessment of the first two steps treatment of conditions such as cancer and
to assess their impact in terms of effectiveness, heart disease, and the emergence of new
efficiency, acceptability, accessibility, value for problems such as AIDS/HIV and BOVINE
money or other indicators of quality. This SPONGIFORM ENCEPHALOPATHY (BSE) have
enables the programme to be reviewed and again showed the importance of prevention and
changed as necessary. a broader approach to health. With it has come
recognition that, while disease may be the
The practice of public health The situ- justification for action, a narrow disease-
ation in the United Kingdom will be described treatment-based approach is not always the
as, even though systems vary, it will give a gen- most effective or economic solution. The role of
eral impression of the type of work covered. the director of public health (the successor to
HISTORY Initially, public-health practice the medical officer of health) is again being
related to food, the urban environment and the expanded, and in 1997 for the first time in
control of infectious diseases. Early examples the UK a government Minister for Public
include rules in the Bible about avoiding certain Health was appointed. This reflects not only a
foods. These were probably based on practical greater priority for public health, but also a
experience, had gradually been adopted as sens- concern that the health effects of policy
ible behaviour, become part of culture and should be considered across all parts of
finally been incorporated into religious laws. government.
Other examples are the regulations about quar- (See also ENVIRONMENT AND HEALTH.)
antine for PLAGUE and LEPROSY in the Middle
Ages, vaccination against SMALLPOX introduced Public Health Laboratory
by William Jenner, and Linds use of citrus Service (PHLS)
fruits to prevent SCURVY at sea in the 18th A statutory organisation that is part of the
century. NHS. It comprises ten laboratory groups and
It was during the 19th century, in response to two centres in the UK, with central coordin-
the health problems arising from the rapid ation from PHLS headquarters. The service
growth of urban life, that the foundations of a provides diagnostic-testing facilities for cases
public-health system were created. The sani- of suspected infectious disease. The remit of
tary concept was fundamental to these devel- the PHLS (which was set up during World War
P opments. This suggested that overcrowding in II and then absorbed into the NHS) is now
insanitary conditions was the cause of most dis- based on legislation approved in 1977 and
ease epidemics and that improved sanitation 1979. Its overall purpose was to protect the
measures such as sewerage and clean water sup- population from infection by maintaining a
plies would prevent them. Action to introduce national capability of high quality for the detec-
such measures were often initiated only after tion, diagnosis, surveillance, protection and
epidemics spread out of the slums and into control of infections and communicable dis-
wealthier and more powerful families. Other eases. It provided microbiology services to hos-
problems such as the stench of the River pitals, family doctors and local authorities as
Thames outside the Houses of Parliament also well as providing national reference facilities. In
led to a demand for effective sanitary control 2001 it was incorporated into the newly estab-
measures. Successive public-health laws were lished NATIONAL INFECTION CONTROL AND
passed by Parliament, initially about sanitation HEALTH PROTECTION AGENCY.
and housing, and then, as scientific knowledge
grew, about bacterial infections. Pudendal Nerve
In the middle of the 19th century the first The nerve that operates the lowest muscles of
medical officers of health were appointed with the floor of the PELVIS and also the anal
responsibility to report regularly and advise SPHINCTER muscle. It may be damaged in
local government about the measures needed to childbirth, resulting in INCONTINENCE.
control disease and improve health. Their scope
and responsibility widened as society changed Pudendum
and took on a wider welfare role. After more The external genital organs. The term is usually
than a century they changed as part of the used to describe those of the female (see VULVA).
reforms of the NHS and local government in
 Pulmonary Embolism 597

Puerperal Depression day of the puerperium. (See also PREGNANCY

Also called postnatal DEPRESSION, this is the AND LABOUR.)
state of depression that may affect women soon
after they have given birth. The condition often Management The mother should start
occurs suddenly a day or so after the birth. practising exercises to help ensure that the
Many women suffer from it and usually they stretched abdominal muscles regain their nor-
can be managed with sympathetic support. If, mal tone. There is no need for any restriction of
however, the depression sometimes called diet, but care must be taken to ensure an
maternal blues persists for ten days or more, adequate intake of fluid, including at least
mild ANTIDEPRESSANT DRUGS are usually 580 ml (a pint) of milk a day.
effective. If not, psychiatric advice is recom- Milk, as already stated, appears copiously on
mended. (See PREGNANCY AND LABOUR.) the third day, but this is preceded by a secretion
from the breast, known as colostrum, which is
Puerperal Sepsis of value to the newborn child. The child should
An infection, once called puerperal fever, that therefore be put to the breasts within 68 hours
starts in the genital tract within ten days after of being born. This also stimulates both the
childbirth, miscarriage or abortion (see PREG- breasts and the natural changes taking place
NANCY AND LABOUR). Once a scourge of during this period. Suckling is beneficial for
childbirth, with many women dying from the both child and mother and encourages bonding
infection, the past 50 years have seen a dra- between the two.
matic decline in its incidence in developed
countries, with only 13 per cent of women Pulmonary
having babies now being affected. This Relating to the LUNGS.
decline is due to much better maternity care
and the advent of ANTIBIOTICS. Infection Pulmonary Diseases
usually starts in the VAGINA and is caused by See LUNGS, DISEASES OF.
the bacteria that normally live in it: they can
cause harm because of the mothers lowered Pulmonary Embolism
resistance, or when part of the PLACENTA has The condition in which an embolus (see EMBOL-
been retained in the genital tract. The infec- ISM), or clot, is lodged in the LUNGS. The
tion usually spreads to the UTERUS and some- source of the clot is usually the veins of the
times to the FALLOPIAN TUBES. Sometimes lower abdomen or legs, in which clot formation
bacteria may enter the vagina from other parts has occurred as a result of the occurrence
of the body. of DEEP VEIN THROMBOSIS (DVT)
Fever, an offensive-smelling post-partum THROMBOPHLEBITIS (see VEINS, DISEASES OF). P
vaginal discharge (lochia) and pain in the lower Thrombophlebitis, with or without pulmonary
abdomen are the main features. Untreated, the embolism, is a not uncommon complication of
women may develop SALPINGITIS, PERITONITIS surgical operations, especially in older patients.
and septicaemia. Antibiotics are used to treat This is one reason why nowadays such patients
the infection and any retained placental tissue are got up out of bed as quickly as possible, or,
must be removed. alternatively, are encouraged to move and exer-
cise their legs regularly in bed. Long periods of
Puerperium sitting, particularly when travelling, can cause
The period which elapses after the birth of a DVT with the risk of pulmonary embolism.
child until the mother is again restored to her The severity of a pulmonary embolism, which
ordinary health. It is generally regarded as last- is characterised by the sudden onset of pain in
ing for a month. One of the main changes to the chest, with or without the coughing up of
occur is the enormous decrease in size that takes blood, and a varying degree of SHOCK, depends
place in the muscular wall of the womb. There upon the size of the clot. If large enough, it may
are often AFTERPAINS during the first day in prove immediately fatal; in other cases,
women who have borne several children, less immediate operation may be needed to remove
often after a first child. The discharge is blood- the clot; whilst in less severe cases anticoagulant
stained for the first two or three days, then treatment, in the form of HEPARIN, is given to
clearer till the end of the first week, before stop- prevent extension of the clot. For some oper-
ping within two or three weeks. The breasts, ations, such as hip-joint replacements, with a
which have already enlarged before the birth of high risk of deep-vein thrombosis in the leg,
the child, secrete milk more copiously, and heparin is given for several days post-
there should be a plentiful supply on the third operatively.
 598 Pulmonary Fibrosis

Pulmonary Fibrosis commonly constrict the small arteries in the

A condition which may develop in both LUNGS lungs, thus causing pulmonary HYPERTENSION.
(interstitial pulmonary fibrosis) or part of one (See also EISENMENGER SYNDROME.)
lung. Scarring and thickening of lung tissues
occur as a consequence of previous lung Pulmonary Oedema
inflammation, which may have been caused by Collection of water in the lungs caused by left
PNEUMONIA or TUBERCULOSIS. Symptoms ventricular failure or MITRAL STENOSIS which
include cough and breathlessness and diagnosis produces back pressure in the LUNGS, thus for-
is confirmed with a chest X-ray. The patients cing fluid into the tissues. (See HEART, DISEASES
underlying condition should be treated, but the OF.)
damage already done to lung tissue is usually
irreversible. (See also ALVEOLITIS.) Pulmonary Stenosis
A disorder of the HEART in which obstruction
Pulmonary Function Tests of the outflow of blood from the right ven-
Tests to assess how the LUNGS are functioning. tricle occurs. Narrowing of the pulmonary
They range from simple spirometry (measuring valve at the exit of the right ventricle and
breathing capacity) to sophisticated physio- narrowing of the pulmonary artery may cause
logical assessments. obstruction. The condition is usually con-
Static lung volumes and capacities can be genital, although it may be caused by
measured: these include vital capacity the RHEUMATIC FEVER. In the congenital condi-
maximum volume of air that can be exhaled tion, pulmonary stenosis may occur with
slowly and completely after a maximum deep other heart defects and is then known as Fal-
breath; forced vital capacity is a similar man- lots tetralogy. Breathlessness and enlargement
oeuvre using maximal forceful exhalation and of the heart and eventual heart failure may be
can be measured along with expiratory flow the consequence of pulmonary stenosis. Sur-
rates using simple spirometry; total lung cap- gery is usually necessary to remove the
acity is the total volume of air in the chest after obstruction.
a deep breath in; functional residual capacity is
the volume of air in the lungs at the end of a Pulmonary Surfactant
normal expiration, with all respiratory muscles Naturally produced in the LUNGS by cells called
relaxed. pneumocytes, this substance is a mixture of
Dynamic lung volumes and flow rates reflect phospholipids (see PHOSPHOLIPID) and LIPO-
the state of the airways. The forced expiratory PROTEINS. Present in fluid lining the alveoli (see
volume (FEV) is the amount of air forcefully ALVEOLUS) in the lungs, their action helps
P exhaled during the first second after a full maintain their patency. Premature babies may
breath it normally accounts for over 75 per have a deficiency of surfactant, a disorder which
cent of the vital capacity. Maximal voluntary causes severe breathing difficulties RESPIRA-
ventilation is calculated by asking the patient to TORY DISTRESS SYNDROME or hyaline mem-
breathe as deeply and quickly as possible for 12 brane disease and HYPOXIA. They will need
seconds; this test can be used to check the urgent respiratory support, which includes oxy-
internal consistency of other tests and the gen and the administration (via an endotracheal
extent of co-operation by the patient, import- tube) of a specially prepared surfactant such as
ant when assessing possible neuromuscular beractant (bovine lung extract) or edfosceril
weakness affecting respiration. There are several palmitate.
other more sophisticated tests which may not
be necessary when assessing most patients. Pulp
Measurement of arterial blood gases is also an See under TEETH.
important part of any assessment of lung
function. Pulsation
Also known as throbbing. An appearance seen
Pulmonary Hypertension or felt naturally below the fourth and fifth ribs
In this condition, increased resistance to the on the left side, where the heart lies, and also at
blood flow through the LUNGS occurs. This is every point where an artery lies close beneath
usually the result of lung disease, and the con- the surface. In other situations, it may be a sign
sequence is an increase in pulmonary artery of ANEURYSM. In thin people, pulsation can
pressure and in the pressure in the right side of often be seen and felt in the upper part of the
the heart and in the veins bringing blood to the abdomen, due to the throbbing of the normal
heart. Chronic BRONCHITIS or EMPHYSEMA abdominal AORTA.
 Purpura 599

Pulse Pulse Oximetry

If the tip of one finger is laid on the front of Measurement of OXYGEN saturation of
the forearm, about 25 cm (one inch) above the HAEMOGLOBIN in a blood sample using a non-
wrist, and about 1 cm (half an inch) from the invasive device called a spectrophotometer.
outer edge, the pulsations of the radial artery
can be felt. This is known as the pulse, but a Pulsus Paradoxus
pulse can be felt wherever an artery of large or A big fall in a persons systolic BLOOD PRESSURE
medium size lies near the surface. when he or she breathes in. It may occur in
The cause of the pulsation lies in the fact conditions such as constrictive PERICARDITIS
that, at each heartbeat, 8090 millilitres of and pericardial effusion, when the normal
blood are driven into the AORTA, and a fluid pumping action of the heart is hindered.
wave, distending the vessels as it passes, is ASTHMA may also cause pulsus paradoxus, as
transmitted along the ARTERIES all over the can CHRONIC OBSTRUCTIVE PULMONARY DIS-
body. This pulsation falls away as the arteries EASE (COPD).
grow smaller, and is finally lost in the minute
capillaries, where a steady pressure is main- Punctate Basophilia
tained. For this reason, the blood in the veins See BASOPHILIA.
flows steadily on without any pulsation.
Immediately after the wave has passed, the Punctum
artery, by virtue of its great elasticity, regains its See EYE Eyelids.
former size. The nature of this wave helps the
doctor to assess the state of the artery and the Puncture
action of the heart. Description of a wound made by a sharp object,
The pulse rate is usually about 70 per min- such as a knife, or by a surgical instrument.
ute, but it may vary in health from 50 to 100, Puncture wounds, whether accidental (e.g.
and is quicker in childhood and slower in old from a car accident) or deliberate (e.g. from a
age than in middle life; it is low (at rest) in fight), are potentially dangerous. Despite an
physically fit athletes or other sports people. often small entry hole, serious damage may
Fever causes the rate to rise, sometimes to 120 have been done to underlying tissues for
beats a minute or more. example, HEART, LUNGS, LIVER, or large blood
In childhood and youth the vessel wall is so vessel and surgical exploration may be
thin that, when sufficient pressure is made to required to assess the extent of the injury. Punc-
expel the blood from it, the artery can no longer tures through the skin are also done deliberately
be felt. In old age, however, and in some in medicine to extract fluid or tissue through a
degenerative diseases, the vessel wall becomes so hollow needle so that it can be examined in the P
thick that it may be felt like a piece of whipcord laboratory. LUMBAR PUNCTURE, where cerebro-
rolling beneath the finger. spinal fluid is withdrawn, is one example.
Different types of heart disease have special
features of the pulse associated with them. In Pupil
atrial FIBRILLATION the great character is See EYE.
irregularity. In patients with an incompetent
AORTIC VALVE the pulse is characterised by a Purgatives
sharp rise and sudden collapse. (See HEART, DIS- See LAXATIVES.
EASES OF.)
An instrument known as the SPHYGMO- Purkinje Cells
GRAPH registers the arterial waves and a poly- Large specialised nerve cells occurring in great
graph (an instrument that obtains simultaneous numbers in the cortex (superficial layer of grey
tracings from several different sources such as matter) of the cerebellum of the BRAIN. They
radial and jugular pulse, apex beat of the heart have a flask-shaped body, an AXON and branch-
and ELECTROCARDIOGRAM (ECG)) enables trac- ing tree-like extensions called dendrites, which
ings to be taken from the pulse at the wrist and extend towards the surface of the brain (see
from the veins in the neck and simultaneous NEURON(E)).
events in the two compared.
The pressure of the blood in various arteries Purpura
is estimated by a SPHYGMOMANOMETER. (See A skin rash caused by bleeding into the skin
BLOOD PRESSURE.) from capillary blood vessels. The discrete
purple spots of the rash are called purpuric
spots or, if very small, petechiae. The disorder
 600 Purulent

may be caused by capillary defects (non- Pyelitis

thrombocytopenic purpura) or be due to a A term describing inflammation of the pelvis of
deficiency of PLATELETS in the blood (thrombo- the kidney. In fact, the inflammation usually
cytopenic purpura). Most worryingly, the rash affects the whole kidney tissue and the descrip-
may be due to a fulminant form of meningo- tion should be PYELONEPHRITIS.
coccal SEPTICAEMIA called purpura fulminans.
(See also HENOCH-SCHNLEIN PURPURA; Pyelogram
IDIOPATHIC THROMBOCYTOPENIC PURPURA See INTRAVENOUS PYELOGRAM (UROGRAM).
(ITP); THROMBOCYTOPENIA.).
Pyelography
Purulent The process whereby the KIDNEYS are rendered
Containing, comprising or forming PUS. radio-opaque, and therefore visible on an X- ray
film. It constitutes a most important part of the
Pus examination of a patient with kidney disease.
Pus is a thick, white, yellow or greenish fluid, (See SODIUM DIATRIZOATE.)
found in abscesses (see ABSCESS), ulcers, and on
inflamed and discharging surfaces generally. Its Pyelolithotomy
colour and consistency are due to the presence Surgery to remove a stone from the kidney (see
of white blood corpuscles, and superficial cells KIDNEYS, DISEASES OF) via an incision in the
of granulation tissue or of a mucous membrane pelvis of the kidney.
which die and are shed off in consequence of
the inflammatory process (see PHAGOCYTOSIS). Pyelonephritis
Bacteria that normally produce pus are Inflammation of the kidney (see KIDNEYS), usu-
STREPTOCOCCUS, PNEUMOCOCCUS and ally the result of bacterial infection. The
ESCHERICHIA coli. inflammation may be acute or chronic. Acute
pyelonephritis comes on suddenly, is com-
Pustule moner in women, and tends to occur when they
A small collection of PUS. Malignant pustule is are pregnant. Infection usually spreads up the
one of the forms of ANTHRAX. URETER from the URINARY BLADDER which has
become infected (CYSTITIS). Fevers, chills and
Putrefaction backache are the usual presenting symptoms.
The change that takes place in the bodies of ANTIBIOTICS should be given, and in severe
plants and animals after death, whereby they cases the intravenous route may be necessary.
are ultimately reduced to carbonic acid gas, SEPTICAEMIA is an occasional complication.
P ammonia, and other simple substances. The Chronic pyelonephritis may start in child-
change is almost entirely due to the action of hood, and the usual cause is back flow of urine
bacteria, and, in the course of the process, from the bladder into one of the ureters per-
various offensive and poisonous intermediate haps because of a congenital deformity of the
substances are formed. In the case of the valve where the ureter drains into the bladder.
human body, putrescine, cadaverine, and other Constant urine reflux results in recurrent infec-
alkaloids are among these intermediate tion of the kidney and damage to its tissue. Full
products. investigation of the urinary tract is essential
and, if an abnormality is detected, surgery may
Putrid Fever well be required to remedy it. HYPERTENSION
An old name for typhus fever (see ENTERIC and renal failure may be serious complications
FEVER). of pyelonephritis (see also KIDNEYS, DISEASES
OF).
PUVA
See PHOTOCHEMOTHERAPY; PSORIASIS. Pylephlebitis
Inflammation of the PORTAL VEIN. A rare but
PVS serious disorder, it usually results from the
See PERSISTENT VEGETATIVE STATE (PVS). spread of infection within the abdomen for
example, appendicitis. The patient may develop
Pyaemia liver abscesses and ASCITES. Treatment is by
A form of blood-poisoning in which abscesses ANTIBIOTICS and surgery.
(see ABSCESS) appear in various parts of the
body. (See also SEPTICAEMIA.) Pyloric Stenosis
Narrowing of the PYLORUS, the muscular exit
 Pyuria 601

from the STOMACH. It is usually the result of a the rounded forms of bacterium (e.g.
pyloric ulcer or cancer near the exit of the streptococcus).
stomach. Food is delayed when passing from
the stomach to the duodenum and vomiting Pyorrhoea
occurs. The stomach may become distended Any copious discharge of PUS. For pyorrhoea
and peristalsis (muscular movement) may be alveolaris, see under TEETH, DISORDERS OF.
seen through the abdominal wall. Unless surgi-
cally treated the patient will steadily deteriorate, Pyrazinamide
losing weight, becoming dehydrated and devel- An antituberculous drug used in combination,
oping ALKALOSIS. usually with RIFAMPICIN and ISONIAZID, as the
A related condition, congenital hypertrophic treatment regime for TUBERCULOSIS. It pene-
pyloric stenosis, occurs in babies (commonly trates the MENINGES so is valuable in treating
boys) about 35 weeks old, and surgery pro- tuberculous MENINGITIS. The drug is some-
duces a complete cure. times associated with liver damage and liver
function tests should be done before using it.
Pyloromyotomy
Also called Ramstedts operation, this is a surgi- Pyrexia
See FEVER.
cal procedure to divide the muscle around the
outlet of the stomach (PYLORUS). It is done
usually on babies to relieve the obstruction
Pyridoxine
Pyridoxine, or vitamin B, plays an important
caused at the outlet by congenital PYLORIC
part in the metabolism of a number of AMINO
STENOSIS.
ACIDS. Deficiency leads to ATROPHY of the EPI-
DERMIS, the hair follicles, and the SEBACEOUS
Pylorospasm glands, and peripheral NEURITIS may also occur.
Spasm of the pyloric portion of the STOMACH.
Young infants are more susceptible to pyrid-
This interferes with the passage of food in a
oxine deficiency than adults: they begin to lose
normal, gentle fashion into the intestine, caus-
weight and develop a hypochromic ANAEMIA;
ing the pain that comes on from half an hour
irritability and CONVULSIONS may also occur.
to three hours after meals; it is associated with
Liver, yeast and cereals are relatively rich sources
severe disorders of digestion. It is often pro-
of the vitamin; fish is a moderately rich source,
duced by an ulcer of the stomach or
but vegetables and milk contain little. The min-
duodenum.
imal daily requirement in the diet is probably
about 2 mg. (See APPENDIX 5: VITAMINS.)
Pylorus
The lower opening of the STOMACH, through Pyrimethamine P
which the softened and partially digested food An antimalarial drug used with either sulfadox-
passes into the small INTESTINE. ine or DAPSONE to treat Plasmodium falciparum
malariae (see MALARIA). It should not be used
Pyo- for PROPHYLAXIS because of potentially severe
A prefix attached to the name of various dis- side-effects when used in the long term.
eases to indicate cases in which PUS is formed,
such as pyonephrosis. Pyromania
A powerful urge in a person to set things on fire.
Pyoderma Gangrenosum Affected individuals, more commonly males,
This is a disorder in which large ulcerating are called pyromaniacs. They usually have a his-
lesions appear suddenly and dramatically in the tory of fascination with fire since childhood and
skin. It is the result of underlying VASCULITIS. It obtain pleasure or relief of tension from causing
is usually the result of inflammatory bowel dis- fires. Treatment is difficult and pyromaniacs
ease such as ULCERATIVE COLITIS or CROHNS commonly end up in the courts.
DISEASE but can be associated with RHEUMA-
TOID ARTHRITIS. Pyrosis
See WATERBRASH.
Pyogenic
Pyogenic is a term applied to those bacteria Pyuria
which cause the formation of PUS and so lead to The presence of PUS in the URINE, in con-
the formation of abscesses (see ABSCESS). sequence of inflammation situated in the KID-
Although many bacteria have this property, the NEYS, URINARY BLADDER or other part of the
most common cause of abscess is one of urinary tract.
 Homonymous quadrantanopia is loss of vision

Q in the same quarter of the field in each EYE.

Quadriceps
(More accurately quadriceps femoris) the
large, four-headed muscle occupying the front
and sides of the thigh, which straightens the leg
QALY at the knee-joint and maintains the body in an
This is an outcome measure of health care upright position. It comprises the rectus femo-
devised by health economists in the 1980s, and ris, vastus lateralis, vastus intermedius and vas-
stands for Quality Adjusted Life Year. It takes a tus medialis.
year of healthy life expectancy to be worth a
grade of 1, and a year of unhealthy life expect- Quadriplegia
ancy to be worth less than 1. The worse the PARALYSIS of the four limbs of the body.
forecast of an unhealthy persons quality of life,
the lower will be his or her rating. If someone is Quadruplets
expected to live five years in a healthy state, the See MULTIPLE BIRTHS.
grading will be 5; ten years of life estimated to
be only 25 per cent healthy will rate as 25 Quantitative Digital
QALYs. The measure has proved controversial Radiography
but nevertheless is an indication of the likely A radiological technique for detecting osteo-
cost-effectiveness of a particular treatment, and porosis (see BONE, DISORDERS OF) in which a
can contribute to assessing whether or not a beam of X-rays is directed at the bone-area
proposed or actual treatment or procedure is under investigation normally the spine and
worthwhile both for patients and for the hip and the CALCIUM density measured. If the
economy. calcium content is low, preventive treatment
can be started to reduce the likelihood of frac-
Q Fever tures occurring.
A disease of worldwide distribution due to the
organism Coxiella burneti. It is characterised by Quarantine
fever, severe headache and often PNEUMONIA. It The principle of preventing the spread of infec-
was first described in 1937 amongst abattoir tious disease by which people, baggage, mer-
workers in Brisbane. The disease was given the chandise, and so forth likely to be infected or
name Q fever, the Q (as in question mark) coming from an infected locality are isolated at
referring to the unknown cause of the disease frontiers or ports until their harmlessness has
when first described. been proven to the satisfaction of the author-
The principal reservoir of human infection ities. (See INFECTION.)
in Britain is probably cattle and sheep in which Originally quarantine, as its name implies,
the infection is usually sub-clinical. The diag- involved detention for 40 days; but the period
nosis is confirmed by the detection of serum now covers the incubation period of the disease,
antibodies to Coxiella burneti. The organism is the presence of which is suspected.
sensitive to tetracycline. Numerous international conferences upon
the subject have been held with the view of
QRS Complex arriving at a uniform practice as regards quaran-
The section of an ELECTROCARDIOGRAM (ECG)
tine in different countries. The diseases to
that precedes the S-T segment and registers
which quarantine applies are CHOLERA, YEL-
contraction of the VENTRICLE of the HEART.
LOW FEVER, PLAGUE, SMALLPOX, TYPHUS FEVER
Q-T Interval and RELAPSING FEVER.
The interval in an ELECTROCARDIOGRAM (ECG) The general practice with regard to quaran-
that registers the electrical activity generated tine is that when a serious disease breaks out in
during ventricular contraction of the HEART. any country, the government of that country
notifies surrounding governments as to the
Quack ports and other places that have become centres
Colloquial description of an unqualified person of infection. Any people travelling from these
claiming to be a medical doctor. centres and attempting to enter another coun-
try, are subject to measures prescribed in the
Quadrantanopia appropriate regulations. These measures vary
Inability to see in one quarter of the visual field. with the disease involved.
 Quintuplets 603

Quartan Fever ANTISEPTICS). Its best-known action is in

Description of intermittent fever with par- checking the recurrence of attacks of MALARIA,
oxysms developing every fourth day. Usually as it destroys malarial parasites in the blood.
applied to MALARIA. In fevers it acts as an antipyretic (see
ANTIPYRETICS).
Quickening Among its side-effects are ringing in the ears,
The first movements of a FETUS in the womb as temporary impairment of vision, and some-
experienced by the mother, usually around the times disturbance of kidney function leading to
16th week of pregnancy (see PREGNANCY AND renal failure.
LABOUR).
Uses The most important use of quinine is its
Quiescent original one in malaria, attacks of which it
The description applied to a disease in an indi- quickly cuts short or prevents altogether. It has
vidual which is in an inactive phase and so been largely replaced by more effective and less
likely to be undiagnosed. toxic antimalarial drugs; however, development
of malarial parasites resistant to newer drugs has
Quinghaosu revived the use of quinine. For intravenous
A herbal drug used for two millennia in China injection, when this is necessary in cases of mal-
to treat MALARIA. Its action derives from ses- aria, a soluble form of quinine, the dihydro-
quiterpene lactone, a substance that cuts the chloride, is used. Quinine can also be given in
number of blood-borne malarial parasites. combination with other antimalarial drugs on
medical advice. The drug is sometimes used in
Quinidine the treatment of cramps.
An alkaloid (see ALKALOIDS) obtained from cin-
chona bark and closely related in chemical Quinolones
composition and in action to QUININE. It is A group of chemically related synthetic ANTI-
commonly used in the form of quinidine sul- BIOTICS. Examples include nalidixic acid,
phate to treat cardiac irregularities such as cinoxacin and norfloxocin which are effective
supraventricular tachycardia and ventricular in treating uncomplicated urinary-tract,
arrhythmias (see HEART, DISEASES OF). respiratory-tract and gastrointestinal infections.
They are usually effective against gram-negative
Quinine and gram-positive bacteria (see GRAMS STAIN).
An alkaloid (see ALKALOIDS) obtained from the Many staphylococci including METHICILLIN-
bark of various species of cinchona trees. This RESISTANT STAPHYLOCOCCUS AUREUS (MRSA)
bark is mainly derived from Peru and neigh- are resistant to quinolones. This group of drugs
bouring parts of South America and the East has a range of potentially troublesome side-
Indies. Other alkaloids and acid substances are effects including nausea, vomiting, DYSPEPSIA, Q
also derived from cinchona bark, such as QUI- abdominal pain, diarrhoea, dizziness, sleep
NIDINE and cinchonine. disorders and PRURITUS.
Quinine is generally used in the form of one
of its salts, such as the sulphate of quinine, or Quinsy
dihydrochloride of quinine. All are sparingly A corruption of cynanche, this is an old name
soluble in water, much more so when taken for a PERITONSILLAR ABSCESS.
along with an acid.
Quintuplets
Action Quinine is a powerful antiseptic (see See MULTIPLE BIRTHS.
 long as two years. The disease begins with

R mental symptoms, the person becoming irrit-

able, restless and depressed. Fever and DYS-
PHAGIA follow. The irritability passes into a
form of MANIA and the victim has great
difficulty in swallowing either food or drink.

Rabies Treatment The best treatment is, of course,

An acute and potentially fatal disease, caused by preventive. Local treatment consists of immedi-
a rhabdovirus called Lyssavirus, which affects ate, thorough and careful cleansing of the
the nervous system of animals, particularly car- wound-surfaces and surrounding skin. This is
nivora, and may be communicated from them followed by a course of rabies vaccine therapy.
to humans. Infection from person to person is Only people bitten (or in certain circum-
very rare, but those in attendance on a case stances, licked) by a rabid animal or by one
should take precautions to avoid being bitten or thought to be infected with rabies need treat-
allowing themselves to be contaminated by the ment; this is with rabies vaccine and antiserum
patients saliva, as this contains the causative and one of the IMMUNOGLOBULINS. A person
virus. previously vaccinated against rabies who is sub-
The disease is ENDEMIC in dogs and wolves sequently bitten by a rabid animal should be
in some countries; an EPIDEMIC may occasion- given three or four doses of the vaccine. The
ally occur. It also occurs in foxes, coyotes and vaccine is also used to give protection to those
skunks, as well as in vampire bats. Thanks to liable to infection, such as kennel-workers and
QUARANTINE measures, since 1897 rabies has veterinary surgeons. Those who develop the dis-
been rare in Great Britain, which still retains ease require intensive care with ventilatory sup-
strict measures (the Rabies Act) to prevent the port, despite which the death rate is very high.
entry of infected animals into the country,
including a six-month quarantine period and RAD
vaccination (see IMMUNISATION). This policy A unit of ionising RADIATION absorbed by an
was relaxed somewhat in 2001 with the launch individual. The acronym stands for radiation
of the Pet Travel Scheme; this allows cats and absorbed dose.
dogs to enter the UK from specified countries
without the need for quarantine, as long as Radial Artery
stringent conditions as to microchipping and This artery arises from the brachial artery at the
vaccinations are met. Full details can be level of the neck of the radius. It passes down
obtained from the Department for the the forearm to the wrist, where it is easily pal-
Environment, Food and Rural Affairs pated laterally. It then winds around the wrist to
(DEFRA) or from a veterinary surgeon engaged the palm of the hand to supply the fingers. (See
in operating the scheme. Six months has to ARTERIES.)
elapse between vaccination against rabies and a
positive blood test before the pet passport can Radial Nerve
be issued. This NERVE arises from the BRACHIAL plexus in
Rabies is highly infectious from the bite of an the axilla. At first descending posteriorly and
animal already affected, but the chance of infec- then anteriorly, it ends just above the elbow by
tion from different animals varies. Thus only dividing into the superficial radial and inter-
about one person in every four bitten by rabid osseous nerves. It supplies motor function to
dogs contracts rabies, whilst the bites of rabid the muscles which extend the arm, wrist, and
wolves and cats almost invariably produce the some fingers, and supplies sensation to parts of
disease. the posterior and lateral aspects of the arm,
forearm and hand.
Symptoms In animals there are two types of
the disease: mad rabies and dumb rabies. In the Radiation
former, the dog (or other animal) runs about, Energy in the form of waves or particles. Radi-
snapping at objects and other animals, unable ation is mainly electromagnetic and is broadly
to rest; in the latter, which is also the final stage classified as ionising and non-ionising. The
of the mad type, the limbs become paralysed former can propel ions from an atom; these
and the dog crawls about or lies still. have an electrical charge and can combine
In humans the incubation period is usually chemically with each other. Ionisation occur-
68 weeks, but may be as short as ten days or as ring in molecules that have a key function in
 Radionuclide 605

living tissue can cause biological damage which Radioactive Isotopes

may affect existing tissue or cause mutations in See ISOTOPE.
the GENES of germ-cell nuclei (see GAMETE;
CELLS). Non-ionising radiation agitates the Radioactivity
constituent atoms of nuclei but is insufficiently Breakdown of the nuclei of some elements
powerful to produce ions. resulting in the emission of energy in the form
Ionising radiation comprises X-RAYS, GAMMA of alpha, beta and gamma rays. Because of this
RAYS and particle radiation. X-rays are part of particle emission, the elements decay into other
the continuous electromagnetic-wave spec- elements. Radium and uranium are naturally
trum: this also includes gamma rays, infra-red occurring radioactive elements. RADIOTHERAPY
radiation, ultraviolet light and visible light. treatment utilises artificially produced isotopes
They have a very short wavelength and very (alternative forms of an element) such as
high frequency, and their ability to penetrate iodine-131 and cobalt-60.
matter depends upon the electrical energy gen-
erating them. X-rays that are generated by Radiographer
100,000 volts can pass through body tissue and An individual trained in the techniques of tak-
are used to produce images popularly known ing X-ray pictures (see X-RAYS) of areas of the
as X-rays. X-rays, generated at several million body is known as a diagnostic radiographer.
volts can destroy tissue and are used in RADIO- One who is trained to treat patients with
THERAPY for killing cancer cells. Gamma rays RADIOTHERAPY is a therapeutic radiographer.
are similar to X-rays but are produced by the
decay of radioactive materials. Particle radi- Radiography
ation, which can be produced electrically or by Diagnostic radiography is the technique of
radioactive decay, comprises parts of atoms examining parts of the body by passing X-RAYS
which have mass as well as (usually) an electrical through them to produce images on fluorescent
charge. screens or photographic plates.
Non-ionising radiation includes ultraviolet
light, radio waves, magnetic fields and ULTRA- Radioimmunoassay
SOUND. Magnetic fields are used in magnetic A technique introduced in 1960 which enables
resonance imaging (MRI) and ultrasound, which the minute quantities of natural substances in
is inaudible high-frequency sound waves, and is the blood such as HORMONES to be measured.
used for both diagnoses and treatment in A radioimmunoassay depends upon the ability
medicine. of an unlabelled hormone to inhibit, by simple
competition, the binding of isotopically
Radiation Sickness labelled hormone by specific ANTIBODIES. The
The term applied to the nausea, vomiting and requirements for a radioimmunoassay include
loss of appetite which may follow exposure to adequate amounts of the hormone; a method
RADIATION for example, at work or the use for labelling the hormone with a radioactive
of RADIOTHERAPY in the treatment of cancer isotope; the production of satisfactory anti-
and other diseases. People exposed to radiation bodies; and a technique for separating R
at work should have that exposure carefully antibody-bound from free hormone. Radio-
monitored so it does not exceed safety limits. immunoassay is more sensitive than the best
Doses of radiation given during radiotherapy bioassay for a given hormone, and the most sen-
treatment are carefully measured: even so, sitive radioimmunoassays permit the detection
patients may suffer side-effects. The phenothi- of picogram (pg = 1012g) and femtogram (fg =
azine group of tranquillisers, such as CHLOR- 1015g) amounts of material.
PROMAZINE, as well as the ANTIHISTAMINE
DRUGS, are of value in the prevention and Radiology
treatment of radiation sickness. See X-RAYS.

Radiculopathy Radionuclide
Radiculopathy is damage to the roots of nerves Radionuclide is another word for a radioactive
where they enter or leave the SPINAL CORD. ISOTOPE. These isotopes are used in a scanning
Causes include ARTHRITIS of the spine, thicken- technique of body tissues. Different types of tis-
ing of the MENINGES, and DIABETES MELLITUS. sue and normal or abnormal tissues absorb
Symptoms include pain, PARAESTHESIA, numb- varying amounts of the isotopes; these differ-
ness and wasting of muscles supplied by the ences are detected, recorded and displayed on a
nerves. Treatment is of the underlying cause. screen.
 606 Radio-Opaque

Radio-Opaque
Substances which absorb X-RAYS, rather than Raloxifene
transmitting them, appear white on X-ray film A drug used to prevent and treat postmenopau-
and are described as radio-opaque. This is true sal osteoporosis (see under BONE, DISORDERS OF).
of bones, teeth, certain types of gall-stones, Its action differs from hormone-replacement
renal stones and contrast media used to drugs in that it does not modify the symptoms
enhance the accuracy of radiographic imaging. of the MENOPAUSE.

Radiotherapy Randomised Controlled Trial

The treatment of disease (mainly CANCER) with A method of comparing the results between
penetrating RADIATION. For many years two or more groups of patients intentionally
RADIUM and X-RAYS were the only sources avail- subjected to different methods of treatment
able, but developments in knowledge led to the or sometimes of prevention. Those subjects
use of powerful X-rays, beta rays or gamma entering the trial have to give their informed
rays, either produced by linear accelerator permission. They are allocated to their respect-
machines or given off by radioactive isotopes ive groups using random numbers, with one
(see ISOTOPE). The latter is rarely used now. group (controls) receiving no active treatment,
Beams of radiation may be directed at the instead receiving either PLACEBO or a trad-
tumour from a distance, or radioactive material itional treatment. Preferably, neither the subject
in the form of needles, wires or pellets may nor the assessor should know which regimen is
be implanted in the body. Sometimes germ-cell allocated to which subject: this is known as a
tumours (see SEMINOMA; TERATOMA) and double-blind trial.
lymphomas (see LYMPHOMA) are particularly
sensitive to irradiation which therefore forms a Ranitidine
major part of management, particularly for An H2-receptor antagonist drug used in the
localised disease. Many head and neck treatment of DUODENAL ULCER by reducing the
tumours, gynaecological cancers, and localised hyperacidity of the gastric juice. The drug
prostate and bladder cancers are curable with blocks the production of histamine produced
radiotherapy. Radiotherapy is also valuable in by mast cells in the stomach lining. Histamine
PALLIATIVE CARE, chiefly the reduction of pain stimulates the acid-secreting cells in the stom-
from bone metastases (see METASTASIS). Side- ach. Ranitidine, like other H2-blocking drugs,
effects are potentially hazardous and these have should be used in combination with an anti-
to be balanced against the substantial potential biotic drug to treat ulcers caused by Helicobacter
benefits. Depending upon the type of therapy pylori infection in the stomach. The drug
and doses used, generalised effects include should be given for up to eight weeks with
lethargy and loss of appetite, while localised repeat courses if ulcers recur.
effects depending on the area treated
include dry, itchy skin; oral infection (e.g. Ranula
thrush see CANDIDA); bowel problems; and A swelling which occasionally appears beneath
R DYSURIA. the tongue, caused by a collection of saliva in
the distended duct of a salivary gland. (See also
Radium MOUTH, DISEASES OF.)
The radiations of radium consist of: (1) alpha
rays, which are positively charged helium Rape
nuclei; (2) beta rays negatively charged elec- A criminal offence in which sexual intercourse
trons; (3) gamma rays, similar to X-RAYS but of takes place with an unwilling partner, female or
shorter wavelength. These days the use of male, under threat of force or violence.
radium is largely restricted to the treatment of Reported rape cases have increased in number
carcinoma of the neck of the womb, the tongue, in recent years, but it is hard to know whether
and the lips. Neither X-rays nor radium super- this is because the incidence of rape has
sede active surgical measures when these are increased or because the victims women and
available for the complete removal of a tumour. men are more willing to report the crime. A
more sympathetic and understanding approach
Radius by the police, courts and society generally has
The outer of the two bones in the forearm. resulted in the provision of greater support for
victims who are usually severely traumatised
Rle psychologically as well as physically. It is argued
See CREPITATIONS. that rape is motivated by a desire to dominate
 Read Codes 607

rather than simply an attempt to achieve sexual confined to the occurrence of dead fingers
gratification. The majority of rapes are probably the fingers (or the toes, ears, or nose) becoming
unreported because of the victims shame, anx- white, numb, and waxy-looking. This condi-
iety about publicity and fear that the rapist will tion may last for some minutes, or may not pass
take reprisals. It is legally recognised that rape off for several hours, or even for a day or two.
can happen within marriage. There are moves
to make court proceedings less traumatic for Treatment People who are subject to these
victims, whose attackers are often known to attacks should be careful in winter to protect
them. the feet and hands from cold, and should
Anxiety, DEPRESSION and POST-TRAUMATIC always use warm water when washing the
STRESS DISORDER (PTSD) are common after hands. In addition, the whole body should be
rape: many victims are now given help by rape kept warm, as spasm of the arterioles in the feet
crisis counselling. A recent report suggests that and hands may be induced by chilling of the
in at least 50 per cent of reported rapes, the body. Sufferers should not smoke. VASO-
attacker was known to, or had been a friend of, DILATORS are helpful, especially the calcium
the victim. The deliberate misuse of alcohol or antagonists. In all patients who do not respond
drugs to reduce a potential victims resistance to such medical treatment, surgery should be
seems to be increasing (see DRUG ASSISTED RAPE; considered in the form of sympathectomy: i.e.
FLUNITRAZEPAM.) cutting of the sympathetic nerves to the affected
part. This results in dilatation of the arterioles
Raphe and hence an improved blood supply. This
A ridge or furrow between the halves of an operation is more successful in the case of the
organ. feet than in the case of the hands.

Rarefaction RCN
Diminution in the density of a BONE as a result Stands for Royal College of Nursing.
of withdrawal of calcium salts from it. (See
BONE, DISORDERS OF Osteoporosis.) Reactive Arthritis
An aseptic (that is, not involving infection)
Rash ARTHRITIS secondary to an episode of infection
See ERUPTION. elsewhere in the body. It often occurs in associ-
ation with ENTERITIS caused by salmonella (see
Rat-Bite Fever FOOD POISONING) and certain SHIGELLA
An infectious disease following the bite of a rat. strains, and in both YERSINEA and CAMPYLO-
There are two causative organisms Spirillum BACTER enteritis. Non-gonococcal urethritis,
minus and Actinobacillus muris and the incu- usually due to CHLAMYDIA, is another cause
bation period depends upon which is involved. of reactive arthritis; Reiters syndrome is a
In the case of the former it is 530 days; in the particularly florid form, characterised by muco-
case of the latter it is 210 days. The disease is cutaneous and ocular lesions.
characterised by fever, a characteristic skin rash The SYNOVITIS usually starts acutely and is R
and often muscular or joint pains. It responds frequently asymmetrical, with the knees and
well to PENICILLIN. ankles most commonly affected. Often there
are inflammatory lesions of tendon sheaths and
Raynauds Disease entheses (bone and muscle functions) such as
So called after Maurice Raynaud (183481), plantar fasciitis (see FASCIITIS). The severity and
the Paris physician who published a thesis on duration of the acute episode are extremely
the subject in 1862. This is a condition in variable. Individuals with the histocompat-
which the circulation (see CIRCULATORY SYSTEM ibility antigen HLA B27 are particularly prone
OF THE BLOOD) becomes suddenly obstructed to severe attacks.
in outlying parts of the body. It is supposed to
be due to spasm of the smaller arteries in the Read Codes
affected part, as the result of them responding These form an agreed UK thesaurus of health-
abnormally to impuilses from the SYMPATHETIC care terminology named after the general prac-
NERVOUS SYSTEM. Its effects are increased both titioner who devised them initially in the
by cold and by various diseases involving the 1970s. The coding system provides a basis for
blood vessels. computerised clinical records that can be shared
across professional and administrative boundar-
Symptoms The condition is most commonly ies. Such records have essential safeguards for
 608 Receptor

security and confidentiality. The codes accom- Recovered Memory Syndrome

modate the different views of specialists, but use See REPRESSED MEMORY THERAPY.
simple terms without any loss of the fine detail
necessary in specialist terminology. The Read Recovery Position
Codes are being merged with the worlds other If an individual is unconscious whether as a
leading coding and classification system: the result of accident or illness or when in the post-
College of American Pathologists Systemised operative recovery unit but is breathing and
Nomenclature of Medicine (SNOMED-RT). has a pulse, he or she should be placed in the
recovery position. The individual is turned on
Receptor his or her side to allow the tongue to fall for-
(1) Organs, which may consist of one cell or a wards and so reduce the likelihood of pharyn-
small group of cells, that respond to different geal obstruction (see PHARYNX). Fluid in the
forms of external or internal stimuli by convey- mouth can also drain outwards instead of into
ing impulses down nerves to the CENTRAL NER- the TRACHEA and LUNGS. The person can lie on
VOUS SYSTEM, alerting it to changes in the either side with upper or lower leg flexed.
internal or external environment. Sometimes the semi-prone position is used; this
(2) A small, discrete area on the cell membrane gives better drainage from the mouth and
or within the cell with which molecules or greater stability during transport, but makes it
molecular complexes (e.g. hormones, drugs, more difficult to observe the face, colour or
and other chemical messengers) interact. When breathing. (See APPENDIX 1: BASIC FIRST AID.)
this interaction takes place it initiates a change
in the working of the cell. Recrudescence
The reappearance of a disease after a period
Recessive without signs or symptoms of its presence.
Tending to recede. In genetic terms, a recessive
gene is one whose expression remains dormant Rectum
if paired with an unlike allele. The trait will The last part of the large INTESTINE. It pursues
only be manifest in an individual homozygous a more or less straight course downwards
for the recessive gene. (See GENES.) through the cavity of the pelvis, lying against
the sacrum at the back of this cavity. This sec-
Recombinant DNA tion of the intestine is about 23 cm (9 inches)
DNA or deoxyribonucleic acid containing long: its first part is freely movable and corres-
GENES from various sources that have been com- ponds to the upper three pieces of the sacrum;
bined by GENETIC ENGINEERING. the second part corresponds to the lower two
pieces of the sacrum and the coccyx; whilst the
Recombinant DNA Technology third part, known also as the anal canal, is
See GENETIC ENGINEERING. about 25 mm (1 inch) long, runs downwards
and backwards, and is kept tightly closed by the
Reconstructive (Plastic) Surgery internal and external SPHINCTER muscles which
R Reconstructive surgery on the skin and under- surround it. The opening to the exterior is
lying tissues that have been damaged or lost as known as the ANUS. The structure of the rec-
a result of disease or injury. Congenital mal- tum is similar to that of the rest of the
formations are also remedied using reconstruct- intestine.
ive surgery. Surgeons graft healthy skin from
another part of the body to repair skin dam- Rectum, Diseases of
aged or destroyed by burns or injuries. New The following are described under their separ-
techniques are under development for growing ate dictionary entries: FAECES; HAEMORRHOIDS;
new skin in the laboratory to be used in FISTULA; DIARRHOEA; CONSTIPATION.
reconstructive surgery. Surgeons also repair
damage using skin flaps prepared in another Imperforate anus, or absence of the anus,
part of the body for example, a skin flap from may occur in newly born children, and the
the arm may be used to repair a badly injured condition is relieved by operation.
nose or face. Reconstructive surgery is also used
to repair the consequences of an operation for Itching at the anal opening is common and
cancer of, say, the neck or the jaw. Plastic sur- can be troublesome. It may be due to slight
geons undertake cosmetic surgery to improve abrasions, to piles, to the presence of thread-
the appearance of noses, breasts, abdomens and worms (see ENTEROBIASIS), and/or to anal sex.
faces. The anal area should be bathed once or twice a
 Referred Pain 609

day; clothing should be loose and smooth. generally insidious. The tumour begins com-
Local application of soothing preparations con- monly in the mucous membrane, its structure
taining mild astringents (bismuth subgallate, resembling that of the glands with which the
zinc oxide and hamamelis) and CORTICO- membrane is furnished, and it quickly infil-
STEROIDS may provide symptomatic relief. trates the other coats of the intestine and then
Proprietary preparations contain lubricants, invades neighbouring organs. Secondary
VASOCONSTRICTORS and mild ANTISEPTICS. growths in most cases occur soon in the lymph-
atic glands within the abdomen and in the
Pain on defaecation is commonly caused by a liver. The symptoms appear gradually and con-
small ulcer or fissure, or by an engorged haem- sist of diarrhoea, alternating with attacks of
orrhoid (pile). Haemorrhoids may also cause an constipation, and, later on, discharges of blood
aching pain in the rectum. (See also or blood-stained fluid from the bowels,
PROCTALGIA.) together with weight loss and weakness. A
growth can be well advanced before it causes
Abscess in the cellular tissue at the side of much disturbance. Treatment is surgical and
the rectum known from its position as an usually this consists of removal of the whole of
ischio-rectal abscess is fairly common and the rectum and the distal two-thirds of the
may produce a fistula. Treatment is by ANTI- sigmoid colon, and the establishment of a
BIOTICS and, if necessary, surgery to drain the COLOSTOMY. Depending upon the extent of
abscess. the tumour, approximately 50 per cent of the
patients who have this operation are alive and
Prolapse or protrusion of the rectum is well after five years. In some cases in which the
sometimes found in children, usually between growth occurs in the upper part of the rectum,
the ages of six months and two years. This is it is now possible to remove the growth and
generally a temporary disorder. Straining at preserve the anus so that the patient is saved
defaecation by adults can cause the lining of the the discomfort of having a colostomy. RADIO-
rectum to protrude outside the anus, resulting THERAPY and CHEMOTHERAPY may also be
in discomfort, discharge and bleeding. Treat- necessary.
ment of the underlying constipation is essential
as well as local symptomatic measures (see above). Recurrent Laryngeal Nerve
Haemorrhoids sometimes prolapse. If a return A branch of the vagus NERVE which leaves the
to normal bowel habits with the production of latter low down in its course, and hooking
soft faeces fails to restore the rectum to normal, around the right subclavian artery on the right
surgery to remove the haemorrhoids may be side and round the arch of the aorta on the left
necessary. If prolapse of the rectum recurs, des- runs up again into the neck, where it enters
pite a return to normal bowel habits, surgery the larynx and supplies branches to the muscles
may be required to rectify it. which control the vocal cords.

Tumours of small size situated on the skin Red Blood Cell

near the opening of the bowel, and consisting of See ERYTHROCYTES; BLOOD. R
nodules, tags of skin, or cauliflower-like excres-
cences, are common, and may give rise to pain, Red Cross
itching and watery discharges. These are easily See FIRST AID.
removed if necessary. Polypi (see POLYPUS)
occasionally develop within the rectum, and Reduction
may give rise to no pain, although they may The manipulation of part of the body from an
cause frequent discharges of blood. Like polypi abnormal position to the correct one (e.g. frac-
elsewhere, they may often be removed by a tures, dislocations or hernias).
minor operation. (See also POLYPOSIS.)
Reduction Division
Cancer of the rectum and colon is the com- See MEIOSIS.
monest malignancy in the gastrointestinal tract:
around 17,000 people a year die from these Referred Pain
conditions in the United Kingdom. Rectal can- Pain felt in one part of the body which is actu-
cer is more common in men than in women; ally arising from a distant site (e.g. pain from
colonic cancer is more common in women. the diaphragm is felt at the shoulder tip). This
Rectal cancer is a disease of later life, seldom occurs because both sites develop from similar
affecting young people, and its appearance is embryological tissue and therefore have
 610 Reflex Action

common pain pathways in the CENTRAL NER- eye). The refractive power of the lens can
VOUS SYSTEM. (See also PAIN.) change, whereas that of the cornea is fixed. (For
errors of refraction, see under EYE, DISORDERS
Reflex Action OF.)
One of the simplest forms of activity of the
nervous system. (For the mechanism upon Refractory
which it depends, see NERVOUS SYSTEM; NEUR- Unresponsive or resistant to treatment.
ON(E).) Reflex acts are divided usually into three
classes. Regimen
A course of treatment possibly combining
Superficial reflexes comprise the sudden drugs, exercise, diet, etc. designed to bring
movements which result when the skin is about an improvement in health.
brushed or pricked, such as the movement of
the toes that results from stroking the sole of Regional Anaesthesia
the foot. See ANAESTHESIA Local anaesthetics.

Deep reflexes depend upon the state of Regional Ileitis

mild contraction in which muscles are con- See ILEITIS.
stantly maintained when at rest, and are
obtained, as in the case of the knee-jerk (see Registrar
below), by sharply tapping the tendon of the (1) Divided into specialist registrar and GP
muscle in question. registrar, this is a training grade for NHS doc-
tors. After a period in this grade usually 36
Visceral reflexes are those connected with years they may be appointed as GP prin-
various organs, such as the narrowing of the cipals or gain a certificate of specialist training
pupil when a bright light is directed upon the and be able to apply for NHS consultant
EYE, and the contraction of the URINARY BLAD- posts (provided they have passed the appropri-
DER when distended by urine. ate higher examinations). In 2004 there were
Faults in these reflexes give valuable evidence almost 15,000 specialist registrars in the UK
as to the presence and site of neurological dis- and more than 1,800 GP registrars. Registrar
orders. Thus, absence of the knee-jerk, when numbers are also regulated by the government
the patellar tendon is tapped, means some to achieve a balance between the numbers in
interference with the sensory nerve, nerve-cells, training and the likely number of vacancies
or motor nerve upon which the act depends for career-grade doctors or dentists in the
as, for example, in POLIOMYELITIS, or per- future.
ipheral NEURITIS; whilst an exaggerated jerk (2) A public official responsible for registering
implies that the controlling influence exerted by births, deaths, and marriages.
the BRAIN upon this reflex mechanism has been
cut off as, for example, by a tumour high up Regulation of Health
R in the SPINAL CORD, or in the disease known as Professions
MULTIPLE SCLEROSIS (MS). Professional staff working in health care are
registered with and regulated by several statu-
Reflux tory bodies: doctors by the GENERAL MEDICAL
Fluid flowing in the opposite direction to nor- COUNCIL (GMC); dentists by the GENERAL DEN-
mal (i.e. back flow). Often refers to regurgita- TAL COUNCIL; nurses and midwives by the
tion of stomach contents into the OESOPHAGUS Council for Nursing and Midwifery, formerly
(see also OESOPHAGUS, DISEASES OF), or of urine the UK Central Council for Nursing, Mid-
from the URINARY BLADDER back into the wifery and Health Visiting (see NURSING);
ureters (see URETER). PHARMACISTS by the Royal Pharmaceutical
Society; and the professions supplementary to
Refraction medicine (chiropody, dietetics, medical labora-
The deviation of rays of light on passing from tory sciences, occupational therapy, orth-
one transparent medium into another of differ- optics, physiotherapy and radiography) by the
ent density. The refractive surfaces of the EYE Council for Professions Supplementary to
are the anterior surface of the cornea (which Medicine. In 2002, the Council for the Regu-
accounts for approximately two-thirds of the lation of Health Care Professions was set up
focusing or refractive power of the eye), and as a statutory body that will promote co-
the lens (one-third of the focusing power of the operation between and give advice to existing
 Relapsing Fever 611

regulatory bodies, provide a quality-control Rejection

mechanism, and play a part in promoting the A term used in transplant medicine (see
interests of patients. The new Council is TRANSPLANTATION) to describe the bodys
accountable to a Select Committee of Parlia- immunological response to foreign tissue (see
ment and is a non-ministerial government IMMUNITY). Various drugs, such as
department similar in status to the FOOD CICLOSPORIN A, can be used to dampen the
STANDARDS AGENCY. It has the right to scru- hosts response to a graft or organ transplant
tinise the decisions of its constituent bodies and reduce the risk of rejection.
and can apply for judicial review if it feels
that a judgement by a disciplinary committee Relapse
has been too lenient. The return of a disease that a patient has had
and apparently recovered from. It may also be a
Regurgitation worsening of a disease from which a person is
Regurgitation is a term used in various connec- still recovering.
tions in medicine. For instance, in diseases of
the HEART it is used to indicate a condition in Relapsing Fever
which, as the result of valvular disease, the So-called because of the characteristic tempera-
blood does not entirely pass on from the atria of ture chart showing recurring bouts of fever, this
the heart to the ventricles, or from the ventricles is an infectious disease caused by SPIROCHAETE.
into the arteries. The defective valve is said to There are two main forms of the disease.
be incompetent, and a certain amount of blood
leaks past it, or regurgitates back, into the cavity Louse-borne relapsing fever is an EPI-
from which it has been driven. (See HEART, DEMIC disease, usually associated with wars and
DISEASES OF.) famines, which has occurred in practically every
The term is also applied to the return to the country in the world. For long confused with
mouth of food already swallowed and present in TYPHUS FEVER and typhoid fever (see ENTERIC
the gullet or stomach (see also REFLUX). FEVER), it was not until the 1870s that the
causal organism was described by Obermeier. It
Rehabilitation is now known as the Borrelia recurrentis, a
The restoration to health and working capacity motile spiral organism 1020 micrometres in
of a person incapacitated by disease mental or length. The organism is transmitted from per-
physical or by injury. Treatment usually son to person by the louse, Pediculus humanus.
includes OCCUPATIONAL THERAPY, PHYSIO-
THERAPY and PSYCHOTHERAPY depending Symptoms The incubation period is up to 12
upon the type of disease or injury. Rehabilita- days (but usually seven). The onset is sudden,
tion is commonly carried out at special centres, with high temperature, generalised aches and
either on a daily or a residential basis. This pains, and nose-bleeding. In about half of cases,
allows different types of specialists to co-operate a rash appears at an early stage, beginning in the
in the patients rehabilitation. (See also DISABLED neck and spreading down over the trunk and
PERSONS.) arms. JAUNDICE may occur; and both the LIVER R
and the SPLEEN are enlarged. The temperature
Reiters Syndrome subsides after five or six days, to rise again in
A condition probably caused by an immuno- about a week. There may be up to four such
logical response to a virus (see IMMUNITY), in relapses (see the introductory paragraph above).
which the patient has URETHRITIS, ARTHRITIS
and conjunctivitis (see under EYE, DISORDERS Treatment Preventive measures are the same
OF). The skin may also be affected by horny as those for typhus. Rest in bed is essential, as
areas which develop in it. The disorder was first are good nursing and a light, nourishing diet.
described by a German physician, H. Reiter There is usually a quick response to PENICILLIN;
(18811969); it is more common in men than the TETRACYCLINES and CHLORAMPHENICOL
in women, and is the most common cause of are also effective. Following such treatment the
arthritis in young men. It usually develops in incidence of relapse is about 15 per cent. The
people who have a genetic predisposition for it: mortality rate is low, except in a starved
around 80 per cent of sufferers have the HLA population.
B27 tissue type. Treatment is symptomatic with
ANALGESICS and NON-STEROIDAL ANTI- Tick-borne relapsing fever is an
INFLAMMATORY DRUGS (NSAIDS). (See also ENDEMIC disease which occurs in most tropical
REACTIVE ARTHRITIS.) and sub-tropical countries. The causative
 612 Relate Marriage Guidance

organism is Borrelia duttoni, which is transmit- treatment and there are no signs or symptoms
ted by a tick, Ornithodorus moubata. David present.
Livingstone suggested that it was a tick-borne
disease, but it was not until 1905 that Dutton Remittent Fever
and Todd produced the definitive evidence. The term applied to the form of fever in which,
during remissions (see REMISSION), the tempera-
Symptoms The main differences from the ture falls, but not to normal.
louse-borne disease are: (a) the incubation
period is usually shorter, 36 days (but may be REM Sleep
as short as two days or as long as 12); (b) the Rapid-eye-movement is a stage during SLEEP in
febrile period is usually shorter, and the afebrile which the eyes are seen to move rapidly beneath
periods are more variable in duration, some- the lids and during which dreaming occurs. It
times only lasting for a day or two; (c) relapses occurs for several minutes at a time approxi-
are much more numerous. mately every 100 minutes.
Treatment Preventive measures are more Renal
difficult to carry out than in the case of the Related to the KIDNEYS.
louse-borne infection. Protective clothing
should always be worn in tick country, and Renal Cell Carcinoma
old, heavily infected houses should be des- See HYPERNEPHROMA.
troyed. Curative treatment is the same as for the
louse-borne infection. Renal Diseases
See KIDNEYS, DISEASES OF.
Relate Marriage Guidance
The idea of a marriage-guidance council came
from a group of doctors, clergy and social work-
Renal Tubule
See KIDNEYS.
ers who were concerned for the welfare of mar-
riage. It is based upon two major concepts: that
marriage provides the best possible way for a
Renin
An ENZYME produced by the kidney (see KID-
man and woman to live together and rear their
NEYS) and released into the blood in response to
children; and that the counsellors share a basic
STRESS. Renin reacts with a compound pro-
respect for the unique personality of the indi-
duced by the liver to produce ANGIOTENSIN.
vidual and his (or her) right to make his (or her)
This causes blood vessels to constrict and raises
own decisions. The organisation consists of
the blood pressure. If too much renin is
between 120 and 130 Marriage Guidance
produced, this results in renal HYPERTENSION.
Councils throughout the country, comprising
about 1,250 counsellors. These Councils are
affiliated to Relate National Marriage Guid-
Rennin
A milk-coagulating ENZYME produced by the
ance, which is responsible for the selection,
lining of the stomach. Rennin converts milk
R training and continued supervision of all coun-
protein (caseinogen) into insoluble casein, thus
sellors. Anyone seeking help can telephone or
ensuring that milk stays in the stomach for
write for an appointment. No fees are charged,
some time, during which it can be digested by
but those receiving help are encouraged to
various enzymes before passing into the small
donate what they can.
intestine.
Relaxation Therapy
This is a treatment in which patients are helped Renography
to reduce their levels of anxiety by reducing The radiological examination of the KIDNEYS
their muscle tone. It can be used on its own or using a gamma camera. This is a device that can
in conjunction with a broader PSYCHOTHERAPY follow the course of an injected radioactive (see
regime. The technique guides people on how to RADIOACTIVITY) compound which is concen-
cope with stressful situations and deal with trated and excreted by the kidneys. This
phobias see PHOBIA. provides information on kidney function.

Relenza Repetitive Strain Injury (RSI)

See ZANAMOVIR. See UPPER LIMB DISORDERS.

Remission Repressed Memory Therapy

A period when a disease has responded to Also called recovered memory syndrome, this
 Research Fraud and Misconduct 613

treatment was developed in the wake of the Ethics of research Although Britain has
widespread exposure in the 1980s and 90s of had legislation governing aspects of research on
the frequency of child sexual abuse. A contro- animals since the 19th century, there is no over-
versial concept emerged in the USA, picked up arching statute regulating research on humans
later by some experts in the UK, that abused and human material. Such activity is covered in
children sometimes suppress their unpleasant law by the vaguely defined common-law con-
memories, and that subsequent PSYCHO- cept of consent, and by piecemeal legislation
THERAPY could help some victims to recover such as the DATA PROTECTION ACT 1998 and the
these memories thus possibly aiding rehabili- HUMAN FERTILISATION & EMBRYOLOGY ACT
tation. This recall of repressed memories, 1990. Nevertheless, extensive and very detailed
however, was believed by some psychiatrists to ethical guidance on aspects of research has been
be, in effect, a false memory implanted into the published by a wide range of national and
victims subconscious by the psychotherapy international organisations (see ETHICS COM-
itself or perhaps invented by the individual MITTEES). Several basic principles feature in all
for personal motives. statements about research ethics: these include
In 1997 the Royal College of Psychiatrists in the importance of ensuring that research is
the UK produced a comprehensive report independently and rigorously scrutinised by
which was sceptical about the notion that the appropriately constituted ethics committees;
awareness of recurrent severe sexual abuse in verifying that any risk to the research subject is
children could be pushed entirely out of con- reasonable in relation to the anticipated benefit;
sciousness. The authors did not believe that and ensuring that all efforts are made to min-
events could remain inaccessible to conscious imise possible harm. The research subjects will-
memory for decades, allegedly provoking vague ingness to tolerate some risk does not relieve
non-specific symptoms to be recovered during researchers of the responsibility of making sure
psychotherapy with resolution of the symp- that all risks are kept to a minimum. Above all,
toms. Supporting evidence pointed to the lack a key feature of ethical research has involved
of any empirical proof that unconscious dis- seeking informed consent from research parti-
sociation of unpleasant memories from cipants. This rule, initially applied to actual
conscious awareness occurred to protect the involvement by human subjects in research, has
individual. Furthermore, experimental and gradually been extended to include seeking
natural events had shown that false memories, informed consent from patients or from their
created through suggestion or influence, could relatives to the use of data and to the use of
be implanted. Many individuals who had human organs and tissue in research, including
claimed to have recovered memories of abuse after POST-MORTEM EXAMINATION. (See also
subsequently withdrew and, often, non-specific EVIDENCE-BASED MEDICINE.)
symptoms allegedly linked to suppression wors-
ened rather than improved as therapy to unlock Research Fraud and Misconduct
memories proceeded. The conclusion is that Research misconduct is defined as behaviour by
recovered memory therapy should be viewed a researcher that falls short of good ethical and
with great caution. scientific standards whether or not this be R
intentional. For example, the same data may be
Reproductive System sent for publication to more than one medical
A collective term for all the organs involved in journal, which might have the effect of their
sexual reproduction. In the female these are the being counted twice in any META-ANALYSIS or
OVARIES, FALLOPIAN TUBES, UTERUS, VAGINA systematic review; or the data may be salami
and VULVA. In the male these are the testes (see sliced to try to make the maximum number of
TESTICLE), VAS DEFERENS, SEMINAL VESICLES, publications, even though the data may overlap.
URETHRA and PENIS. Fraud in the context of research is defined as the
generation of false data with the intent to
Research deceive. It is much less frequent than careless-
In medicine, the collation and assessment of ness, but its incidence is estimated as between
existing facts and knowledge, and the critical 0.1 and 1 per cent. A figure of 1 per cent means
systematic investigation of the normal and that, in the United Kingdom at any one time,
abnormal functioning of the body, along with maybe 30 studies are being conducted, or their
the EPIDEMIOLOGY of diseases and disorders results published, which could contain false
affecting it the aim being to increase the sum information. Examples include forged ethics-
of knowledge in respect of the prevention, committee approval, patient signatures and
diagnosis and treatment of disease. diary cards; fabricated figures and results;
 614 Resection

invention of non-existent patient subjects; or be used as an anti-hypertensive (see HYPERTEN-

sharing one electrocardiogram or blood sample SION) and a tranquillising agent.
amongst many subjects.
Research fraud should be first suspected by a Reserve Volume
clinical-trial monitor who recognises that data The additional amount of air that a person
are not genuine, or by a quality-assurance could breathe in or out if he or she were not
auditor who cannot reconcile data in clinical- using the full capacity of their LUNGS. (See also
trial report forms with original patient records. LUNG VOLUMES.)
Unfortunately, it often comes to light by
chance. There may be suspicious similarities Residual Volume
between data ostensibly coming from more The amount of air left in the LUNGS after an
than one source, or visits may have been individual has breathed out as much as possible.
recorded when it was known that the clinic was It is a measure of lung function: for example, in
shut. Statistical analysis of a likely irregularity a person with EMPHYSEMA the residual volume
will frequently confirm such suspicion. The is increased. (See RESPIRATION; LUNG
motivation for fraud is usually greed, but a VOLUMES.)
desire to publish at all costs, to be the original
author of a medical breakthrough, to bolster Resistance
applications for research grants, or to In a medical context, resistance has several
strengthen a bid for more departmental meanings. The walls of blood vessels exert
resources are other recognised reasons for resistance to the flow of blood and this rises as
committing fraud. the diameters of the vessels diminish. This in
In the USA, those proved to have committed turn leads to a rise in blood pressure: the phe-
fraud are debarred from receiving federal funds nomenon may be physiological or pathological.
for research purposes or from undertaking Resistance may also mean the extent of the
government-funded therapeutic research. The bodys IMMUNITY an indication of its ability
four Nordic countries (Denmark, Finland, to withstand disease. Another meaning relates
Norway and Sweden) have committees on to the development of resistance in a bacterium
research dishonesty that investigate all cases of (see BACTERIA) to the effects on it of
suspected research misconduct. In the United ANTIBIOTICS.
Kingdom, an informal system operated by the In PSYCHOANALYSIS, resistance refers to the
pharmaceutical industry, using the disciplinary blocking-off from a persons consciousness of
mechanism of the General Medical Council repressed emotions and memories. A psycho-
(GMC), has led to more than 16 doctors in the analyst helps the patient to break this resistance
past ten years being disciplined for having and bring the repressed material out into the
committed research fraud. Editors of many of open. (See also REPRESSED MEMORY THERAPY.)
the worlds leading medical journals have
united to form the Committee on Publishing Resistin
Ethics, which advises doctors on proper practice A new hormone (see HORMONES) recently iden-
R and assists them in retracting or refusing to tified by researchers in the United States. It
publish articles found or known to be false. (See links OBESITY to type 2 diabetes (see DIABETES
ETHICS; ETHICS COMMITTEES.) Where an MELLITUS Non-insulin dependent diabetes
author does not offer a satisfactory explanation, mellitus (NIDDM)) and its name is based on
the matter is passed to his or her institution to its action namely, resistance to INSULIN. This
investigate; where an editor or the committee is resistance is a hallmark of this type of diabetes
not satisfied with the result they may pass the and is manifested throughout the body. THIA-
complaint to the appropriate regulatory body, ZOLIDINEDIONE DRUGS, a new class of antidi-
such as the GMC in Britain. abetic drugs that lower insulin resistance, are
mediated by receptors which are abundant in
Resection fat cells, and the researchers claim to have iden-
The name of an operation in which a part of tified a fat-cell PROTEIN that may be responsible
some organ is removed, as, for example, the for this and which they believe to be a hor-
resection of a fragment of dead bone or of a mone; it was also found in high concentrations
diseased section of intestine. in diabetic mice.

Reserpine Resolution
An alkaloid (see ALKALOIDS) obtained from the A term applied to infective processes, to indi-
root of rauwolfia that has been and continues to cate a natural subsidence of the INFLAMMATION
 Respiration 615

without the formation of PUS. Thus a pneu- which contract and reduce its domed shape and
monic lung is said to resolve when the material cause it to descend, pushing down the abdom-
exuded into it is absorbed into the blood and inal organs beneath it.
lymph, so that recovery takes place naturally; an EXPIRATION is an elastic recoil, the diaphragm
inflamed area is said to resolve when the rising and the ribs sinking into the position that
inflammation diminishes and no abscess forms; they naturally occupy, when muscular contrac-
a glandular enlargement is said to resolve when tion is finished. Occasionally, forced expiration
it decreases in size without suppuration. Reso- may occur, involving powerful muscles of the
lution is also used to describe the extent to abdomen and thorax; this is typically seen in
which individual details for example, cell forcible coughing.
structures can be identified by the eye when
using a light microscope. Nervous control Respiration is usually
either an automatic or a REFLEX ACTION, each
Resonance expiration sending up sensory impulses to the
The lengthening and intensification of sound CENTRAL NERVOUS SYSTEM, from which
produced by striking the body over an air- impulses are sent down various other nerves to
containing structure such as the lung. Decrease the muscles that produce inspiration. Several
of resonance is called dullness and increase of centres govern the rate and force of the breath-
resonance is called hyper-resonance. The pro- ing, although all are presided over by a chief
cess of striking the chest or other part of the respiratory centre in the medulla oblongata (see
body to discover its degree of resonance is called under BRAIN Divisions). This in turn is con-
PERCUSSION, and according to the note trolled by the higher centres in the cerebral
obtained, an opinion can be formed as to the hemispheres, so that breathing can be voluntar-
state of consolidation of air-containing organs, ily stopped or quickened.
the presence of abnormal cavities, and the
dimensions and relations of solid and air- Quantity of air The lungs do not com-
containing organs lying together. (See also pletely empty themselves at each expiration and
AUSCULTATION.) refill at each inspiration. With each breath, less
than one-tenth of the total air in the lungs
Resorcinol passes out and is replaced by the same quantity
A white, crystalline, antiseptic substance sol- of fresh air, which mixes with the stale air in the
uble in water, alcohol and oils. It can be used in lungs. This renewal, which in quiet breathing
combination with sulphur to treat ACNE. amounts to about 500 millilitres, is known as
the tidal air. By a special inspiratory effort, an
Respiration individual can draw in about 3,000 millilitres,
The process in which air passes into and out of this amount being known as complemental air.
the lungs so that the blood can absorb oxygen By a special expiratory effort, too, after an
and give off carbon dioxide and water. This ordinary breath one can expel much more than
occurs 18 times a minute in a healthy adult at the tidal air from the lungs this extra amount
rest and is called the respiratory rate. An indi- being known as the supplemental or reserve air, R
vidual breathes more than 25,000 times a day and amounting to about 1,300 millilitres. If an
and during this time inhales around 16 kg of individual takes as deep an inspiration as pos-
air. sible and then makes a forced expiration, the
amount expired is known as the vital capacity,
Mechanism of respiration For the struc- and amounts to around 4,000 millilitres in a
ture of the respiratory apparatus, see AIR PAS- healthy adult male of average size. Figures for
SAGES; CHEST; LUNGS. The air passes rhythmic- women are about 25 per cent lower. The vital
ally into and out of the air passages, and mixes capacity varies with size, sex, age and ethnic
with the air already in the lungs, these two origin.
movements being known as inspiration and Over and above the vital capacity, the lungs
expiration. contain air which cannot be expelled; this is
INSPIRATION is due to a muscular effort which known as residual air, and amounts to another
enlarges the chest, so that the lungs have to 1,500 millilitres.
expand in order to fill up the vacuum that Tests of respiratory efficiency are used to
would otherwise be left, the air entering these assess lung function in health and disease.
organs by the air passages. The increase of the Pulmonary-function tests, as they are known, in-
chest in size from above downwards is mainly clude spirometry (see SPIROMETER), PEAK FLOW
due to the diaphragm, the muscular fibres of METER (which measures the rate at which a
 616 Respiratory Arrest

person can expel air from the lungs, thus testing COAGULATION). The activation of complement
vital capacity and the extent of BRONCHOS- causes white cells to lodge in the pulmonary
PASM), and measurements of the concentration capillaries where they release substances which
of oxygen and carbon dioxide in the blood. (See damage the pulmonary endothelium.
also LUNG VOLUMES.) Respiratory distress syndrome is a complica-
tion of SHOCK, systemic SEPSIS and viral respira-
Abnormal forms of respiration Apart tory infections. It was first described in 1967,
from mere changes in rate and force, respiration and despite advances with assisted ventilation
is modified in several ways, either involuntarily remains a serious disease with a mortality of
or voluntarily. SNORING, or stertorous breath- more than 50 per cent. The maintenance of
ing, is due to a flaccid state of the soft palate adequate circulating blood volume, peripheral
causing it to vibrate as the air passes into the PERFUSION, acid-base balance and arterial oxy-
throat, or simply to sleeping with the mouth genation is important, and assisted ventilation
open, which has a similar effect. COUGH is a should be instituted early.
series of violent expirations, at each of which In newborns the mechanism is diferent,
the larynx is suddenly opened after the pressure being provoked by an inability of the lungs to
of air in the lungs has risen considerably; its manufacture SURFACTANT.
object is to expel some irritating substance from
the air passages. SNEEZING is a single sudden Respiratory Syncytial Virus
expiration, which differs from coughing in that (RSV)
the sudden rush of air is directed by the soft Usually known as RSV, this is one of the MYXO-
palate up into the nose in order to expel some VIRUSES. It is among the major causes of BRON-
source of irritation from this narrow passage. CHIOLITIS and PNEUMONIA among infants aged
CHEYNE-STOKES BREATHING is a type of breath- under 6 months; its incidence has been increas-
ing found in persons suffering from stroke, ing, possibly due to atmospheric pollution.
heart disease, and some other conditions, in
which death is impending; it consists in an Respiratory System
alternate dying away and gradual strengthening All the organs and tissues associated with the
of the inspirations. Other disorders of breathing act of RESPIRATION or breathing. The term in-
are found in CROUP and in ASTHMA. cludes the nasal cavity (see NOSE) and PHARYNX,
along with the LARYNX, TRACHEA, bronchi
Respiratory Arrest (see BRONCHUS), BRONCHIOLES and LUNGS.
Sudden stoppage of breathing which results The DIAPHRAGM and other muscles, such as
from any process that strongly suppresses the those between the RIBS, are also part of the
function of the brains respiratory centre. It respiratory system which is responsible for oxy-
leads to lack of oxygen in the tissues and, if not genating the blood and removing carbon
remedied, to cardiac arrest, brain damage, dioxide from it.
COMA and death. Treatment is artificial respir-
ation (see APPENDIX 1: BASIC FIRST AID) and, if Restless Legs Syndrome
R necessary, artificial ventilation. Causes of A condition in which the patient experiences
respiratory arrest include cardiac arrest, elec- unpleasant sensations, and occasionally
trical injury, overdose of narcotic drugs, pro- involuntary movements, in the legs when at
longed seizures (EPILEPSY), serious head injury, rest, especially at night. No pathological
STROKE or inhalation of noxious material that changes have been identified. It is sometimes
causes respiratory failure. indicative of iron-deficiency ANAEMIA, but in
many cases the cause remains a mystery and the
Respiratory Distress Syndrome variety of cures offered are a testimony to this.
This may occur in adults as
ACUTE RESPIRA- Some anti-epileptic drugs are said to help (see
TORY DISTRESS SYNDROME (ARDS), or in new- EPILEPSY).
born children, when it is also known as
HYALINE MEMBRANE DISEASE. The adult syn- Restriction Enzyme
drome consists of PULMONARY OEDEMA of An endonuclease ENZYME, extracted from BAC-
non-cardiac origin. The process begins when TERIA, that is used to cut DNA into short seg-
tissue damage stimulates the autonomic ner- ments a process essential in GENETIC
vous system, releases vasoactive substances, pre- ENGINEERING.
cipitates complement activation, and produces
abnormalities of the clotting cascade the serial Resuscitation
process that leads to clotting of the blood (see See APPENDIX 1: BASIC FIRST AID. See also DNR.
 Retrospectoscope 617

Retardation Retinoids
Slowing down; developmental delay. Psycho- Any one of a collection of drugs that are derived
motor retardation is a significant slowing down from vitamin A (see APPENDIX 5: VITAMINS).
of speech and activity which eventually leads to They can be taken orally or applied topically,
a person being unable to cope with daily activ- and affect the skin by causing drying and peel-
ities or to maintain personal hygiene. It is a ing, with a reduction in the production of
symptom of severe DEPRESSION. SEBUM. These properties are useful in the
treatment of ACNE and PSORIASIS.
Retching
Retching is an ineffectual form of VOMITING. Retinol
Retinol is the official chemical name of vitamin
Retention of Urine A. (See APPENDIX 5: VITAMINS.)
See URINE RETENTION.
Retinopathy
Reticulocytes See EYE, DISORDERS OF Retina, disorders of.
These are newly formed red blood corpuscles,
in which a fine network can be demonstrated Retractor
by special staining methods. Where a large An instrument for pulling apart the edges of an
number are present, one can infer that the incision to allow better surgical access to the
patient is recovering from ANAEMIA for organs and tissues being operated on.
example, after a previous bleed (HAEMOR-
RHAGE) or as a result of treatment of iron
Retro-
deficiency. A prefix signifying behind or turned backwards.

Reticulo-Endothelial System Retrobulbar Neuritis

Inflammation of the optic nerve behind (rather
This consists of highly specialised cells scattered
than within) the EYE. It usually occurs in young
throughout the body, but found mainly in the
adults and presents with a rapid deterioration in
SPLEEN, BONE MARROW, LIVER, and LYMPH
vision over a few hours. Colour vision is also
nodes or glands. Their main function is the
impaired. Usually vision recovers over a few
ingestion of red blood cells and the conversion
weeks, but colour vision may be permanently
of HAEMOGLOBIN to BILIRUBIN. They are also
lost. It can be associated with certain viral ill-
able to ingest bacteria and foreign colloidal
nesses and with MULTIPLE SCLEROSIS (MS). (See
particles.
also EYE, DISORDERS OF.)

Retina Retrograde
See EYE. Movement in a contrary or backward direction
from normal (e.g. a retrograde pyelogram
Retina, Disorders of introduces dye into the pelvis of the kidney by
See EYE, DISORDERS OF. passing it up the ureters). R
Retinoblastoma Retropharyngeal Abscess
A rare malignant growth of the retina (see EYE) An ABSCESS occurring in the cellular tissue
which occurs in infants. It can sometimes be behind the throat (PHARYNX). It is the result in
discovered at birth because shining a light in the general of disease in the upper part of the
babys pupil produces a white reflection rather SPINAL COLUMN.
than a red one. Alternatively, the infant may
present with a SQUINT or a mass in the abdo- Retrospective Study
men. In 25 per cent of cases there is a family The opposite of a PROSPECTIVE STUDY, involv-
history of the condition and abnormality of ing a historical review of the characteristics of a
chromosome 13 is common (see CHROMO- collection of people to assess MORBIDITY, often
SOMES). It is treated by removing the eye or, if by obtaining and analysing their casenotes. The
affecting both eyes, by laser PHOTOCOAGULA- procedure is commonly used in studying the
TION with or without RADIOTHERAPY. EPIDEMIOLOGY of disease.

Retinoic Acid Retrospectoscope

A synthetic vitamin A derivative. (See APPENDIX A mock-humorous term used by doctors to
5: VITAMINS.) imply that one can always see things more
 618 Retroversion

clearly after the event than at the time. One The cause is not known, but there is evidence
danger of making a judgement on the com- that ASPIRIN may also play a part in its caus-
petence of a doctor treating a patient is that it is ation. Doctors recommend that children
easier to know what was the right thing to have should be given PARACETAMOL in place of
done once you know the end of the story. aspirin. The initial feature is severe, persistent
vomiting and fever. This is followed by out-
Retroversion bursts of wild behaviour, DELIRIUM and CON-
An abnormal position of the UTERUS, occurring VULSIONS terminating in COMA and death,
in about 20 per cent of women, in which its often from liver failure. The MORTALITY rate is
long axis is pivoted backwards in relation to the around 23 per cent, and 50 per cent of the
CERVIX UTERI and VAGINA instead of forwards. survivors may have persistent mental or neuro-
logical disturbances. The younger the patient,
Retrovirus the higher the death rate and the more common
A VIRUS containing ribonucleic acid (RNA) the permanent residual effects. Since aspirin has
which is able to change its genetic material into no longer been licensed for use in children and
deoxyribonucleic acid (DNA) using an ENZYME young people the incidence of the condition has
called reverse transcriptase. This conversion fallen dramatcally. Some cases, previously
enables the retrovirus to become integrated into thought to be Reyes syndrome, have sub-
the host cells DNA. Retroviruses are believed sequently turned out to have been due to cer-
to be involved in the development of some can- tain inherited metabolic diseases and to be
cers; they are also associated with disorders unconnected with aspirin.
linked with an impaired immune system (see
IMMUNITY). HIV is a retrovirus. Rhabdoviruses
Retroviruses are also used in the development A group of viruses which includes the RABIES
of gene therapy (see GENETIC ENGINEERING). virus.

Revalidation Rhesus Factor

The periodic assessment of a doctors profes- See BLOOD GROUPS.
sional competence. Revalidation began in the
UK in 2004, to ensure that those doctors on the Rheumatic Fever
Medical Register of the GENERAL MEDICAL An acute febrile illness, usually seen in children,
COUNCIL (GMC) as active practitioners are cap- which may include ARTHRALGIA, ARTHRITIS,
able of providing appropriate standards of med- CHOREA, carditis (see below) and rash (see ERUP-
ical care. The process depends, amongst other TION). The illness has been shown to follow a
things, upon the doctor being able to demon- beta-haemolytic streptococcal infection (see
strate that he or she has maintained a continu- STREPTOCOCCUS).
ing programme of professional development: Rheumatic fever is now extremely uncom-
lifelong learning. mon in developed countries, but remains
common in developing areas. Diagnosis is
R Reverse Transcriptase based on the presence of two or more major
An ENZYME, usually found in retroviruses (see manifestations endocarditis (see under HEART,
RETROVIRUS), that catalyses the manufacture of DISEASES OF), POLYARTHRITIS, chorea, ERY-
DNA from RNA, enabling the viral RNA to THEMA marginatum, subcutaneous nodules
amalgamate with the DNA of the infected host. or one major and two or more minor ones
fever, arthralgia, previous attacks, raised ESR,
Reverse Transcriptase Inhibitor raised white blood cell count, and ELECTRO-
An agent that prevents the action of the viral CARDIOGRAM (ECG) changes. Evidence of pre-
ENZYME, REVERSE TRANSCRIPTASE, so disrupt- vious infection with streptococcus is also a
ing the viruss colonisation of its target host. criterion.
The reverse transcriptase inhibitor ZIDOVUDINE
is used (in combination with other agents) to Clinical features Fever is high, with attacks
treat HIV infection. of shivering or rigor. Joint pain and swelling
(arthralgia) may affect the knee, ankle, wrist or
Reyes Syndrome shoulder and may migrate from one joint to
A condition, now rare, which occurs predomin- another. TACHYCARDIA may indicate cardiac
antly in young children following a viral infec- involvement. Subcutaneous nodules may occur,
tion of the upper respiratory tract or a viral particularly over the back of the wrist or over
infection such as CHICKENPOX or INFLUENZA. the elbow or knee. Erythema marginatum is a
 Rheumatoid Arthritis 619

red rash, looking like the outline of a map, subcutaneous nodules with necrobiotic (decay-
characteristic of the condition. ing) centres.
Cardiac involvement includes PERICARDITIS,
ENDOCARDITIS, and MYOCARDITIS. The main Causes There is a major immunogenetic pre-
long-term complication is damage to the mitral disposition to rheumatoid arthritis in people
and aortic valves (see HEART). carrying the HLA-DR4 antigen (see HLA SYS-
The chief neurological problem is chorea (St TEM). Other minor immunogenetic factors
Vituss dance) which may develop after the have also been implicated. In addition, there is
acute symptoms have subsided. a degree of familial clustering which suggests
other unidentified genetic factors. Genetic fac-
Chronic rheumatic heart disease oc- tors cannot alone explain aetiology, and
curs subsequently in at least half of those who environmental and chance factors must be
have had rheumatic fever with carditis. The important, but these have yet to be identified.
heart valve usually involved is the mitral; less
commonly the aortic, tricuspid and pulmonary. Epidemiology Rheumatoid arthritis more
The lesions may take 1020 years to develop in commonly occurs in women from the age of 30
developed countries but sooner elsewhere. The onwards, the sex ratio being approximately 4:1.
heart valves progressively fibrose and fibrosis Typical rheumatoid arthritis may occur in ado-
may also develop in the myocardium and peri- lescence, but in childhood chronic SYNOVITIS
cardium. The outcome is either mitral stenosis usually takes one of a number of different pat-
or mitral regurgitation and the subsequent mal- terns, classified under juvenile chronic arthritis.
function of this or other heart valves affected is
chronic failure in the functioning of the heart. Pathology The primary lesion is an inflam-
(see HEART, DISEASES OF). mation of the synovial membrane of joints. The
synovial fluid becomes diluted with inflamma-
Treatment Eradication of streptococcal tory exudate: if this persists for months it leads
infection is essential. Other features are treated to progressive destruction of articular CARTIL-
symptomatically. PARACETAMOL may be pre- AGE and BONE. Cartilage is replaced by
ferred to ASPIRIN as an antipyretic in young inflammatory tissue known as pannus; a similar
children. One of the NON-STEROIDAL ANTI- tissue invades bone to form erosions. Synovitis
INFLAMMATORY DRUGS (NSAIDS) may benefit also affects tendon sheaths, and may lead to
the joint symptoms. CORTICOSTEROIDS may be adhesion fibrosis or attrition and rupture of
indicated for more serious complications. tendons. Subcutaneous and other bursae may
Patients who have developed cardiac-valve be involved. Necrobiotic nodules also occur at
abnormalities require antibiotic prophylaxis sites outside synovium, including the sub-
during dental treatment and other procedures cutaneous tissues, the lungs, the pericardium
where bacteria may enter the bloodstream. Sec- and the pleura.
ondary cardiac problems may occur several dec-
ades later and require replacement of affected Clinical features Rheumatoid arthritis var-
heart valves. ies from the very mild to the severely disabling. R
Many mild cases probably go undiagnosed. At
Rheumatism least 50 per cent of patients continue to lead a
An obsolete medical term which no longer has a reasonably normal life; around 25 per cent are
defined meaning. It remains a lay term covering significantly disabled in terms of work and leis-
any painful condition of the muscles and/or ure activities; and a minority become markedly
joints of the arms, legs or spine. disabled and are limited in their independence.
There is often an early acute phase, followed by
Rheumatoid Arthritis substantial remission, but in other patients
A chronic inflammation of the synovial lining gradual step-wise deterioration may occur, with
(see SYNOVIAL MEMBRANE) of several joints, progressive involvement of an increasing num-
tendon sheaths or bursae which is not due to ber of joints.
SEPSIS or a reaction to URIC ACID crystals. It is The diagnosis of rheumatoid arthritis is
distinguished from other patterns of inflamma- largely based on clinical symptoms and signs.
tory arthritis by the symmetrical involvement of Approximately 70 per cent of patients have
a large number of peripheral joints; by the rheumatoid factor ANTIBODIES in the SERUM
common blood-finding of rheumatoid factor but, because of the large number of false posi-
antibody; by the presence of bony erosions tives and false negatives, this test has very little
around joints; and, in a few, by the presence of value in clinical practice. It may be a useful
 620 Rheumatology

pointer to a worse prognosis in early cases if the Rhinophyma

level is high. X-RAYS may help in diagnosing The condition characterised by swelling of the
early cases and are particularly helpful when NOSE due to enormous enlargement of
considering surgery or possible complications the sebaceous glands which may develop in the
such as pathological fracture. Patients com- later stages of ROSACEA.
monly develop ANAEMIA, which may be partly
due to gastrointestinal blood loss from anti- Rhinoplasty
inflammatory drug treatment (see below). Repair of the NOSE or modification of its shape
by operation. This operation is performed by
Treatment involves physical, pharmaco- reconstructive and ENT (ear, nose and throat)
logical, and surgical measures, together with surgeons alike. It may involve alteration of the
psychological and social support tailored to the bony skeleton of the nose and/or alteration of
individual patients needs. Regular activity the SEPTUM (septorhinoplasty). It is mostly per-
should be maintained. Resting of certain joints formed for cosmetic reasons; however, any dis-
such as the wrist with splints may be helpful at ease process or injury which has caused a defect
night or to assist prolonged manual activities. in the nose may be repaired as well. The latter
Sound footwear is important. Early use of anti- problem would usually involve the utilisation of
rheumatic drugs reduces long-term disability. some form of skin flap, whereas this would not
Drug treatment includes simple ANALGESICS, be required for cosmetic surgical purposes.
NON-STEROIDAL ANTI-INFLAMMATORY DRUGS
(NSAIDS), and slow-acting drugs including Rhinorrhoea
GOLD SALTS (in the form of SODIUM AUROTHI- The persistent discharge of watery mucus from
OMALATE), PENICILLAMINE, SULFASALAZINE, the NOSE. This is a usual symptom as a result of
METHOTREXATE and AZATHIOPRINE. COMMON COLD or consequent upon ALLERGY
The non-steroidal agents are largely effective (perennial rhinitis and HAY FEVER).
in reducing pain and early-morning stiffness,
and have no effect on the chronic inflammatory Rhinoviruses
process. It is important, especially in the elderly, A large group of viruses; to date around 80 dis-
to explain to patients the adverse effects of tinct rhinoviruses have been identified. Their
NSAIDs, the dosage of which can be cut by practical importance is that some of them are
prescribing paracetamol at the same time. responsible for around one-quarter of the cases
Combinations of anti-rheumatic drugs seem of the COMMON COLD.
better than single agents. The slow-acting drugs
take approximately three months to act but Rhizotomy
have a more global effect on chronic inflamma- The surgical operation of cutting a nerve root,
tion, with a greater reduction in swelling and an as, for example, to relieve the pain of TRI-
associated fall in erythrocyte sedimentation rate GEMINAL NEURALGIA.
(ESR) and rise in the level of HAEMOGLOBIN.
Local CORTICOSTEROIDS are useful, given into Rhonchi
R individual joints. Systemic corticosteroids carry A description of the harsh cooing, hissing, or
serious problems if continued long term, but whistling sounds (wheezing) heard by AUSCUL-
may be useful under special circumstances. TATION over the bronchial tubes when they are
Much research is currently going on into the the seat of infection. (See BRONCHITIS.)
use of tumour necrosis factor antagonists such
as INFLIXIMAB and etanercept, but their precise Rhythm Method
role remains uncertain. A method of CONTRACEPTION which attempts
to prevent conception by avoiding intercourse
Rheumatology during the fertile part of the menstrual cycle.
The medical speciality concerned with the (See MENSTRUATION; SAFE PERIOD.)
study and management of diseases of the
JOINTS and CONNECTIVE TISSUE. Ribavirin
Also known as tribavirin, this drug inhibits a
Rh Factor wide variety of DNA and RNA viruses. It is
See BLOOD GROUPS. administered by inhalation to treat severe
BRONCHIOLITIS caused by RESPIRATORY SYN-
Rhinitis CYTIAL VIRUS (RSV), particularly in infants who
Inflammation of the mucous membrane of the also have congenital heart disease. It is not used
NOSE. (See also NOSE, DISORDERS OF.) in uncomplicated bronchiolitis as its benefits
 Rickets 621

are arguable in that circumstance: the babies are while the 11th and 12th are free from any such
likely to recover without treatment. connection and are therefore known as floating
Ribavarin, along with INTERFERON alpha-2b, ribs. Each rib has a head, by which it is joined
is given orally to treat patients with chronic to the upper part of the body of the vertebra
HEPATITIS C infection. It is also used to treat with which it corresponds, as well as to the ver-
LASSA FEVER. tebra immediately above. The greater part of
the bone is made up of the shaft, which runs at
Riboflavin first outwards and at the angle turns sharply
The British Pharmacopoeia name for what used forwards. On the lower margin of the shaft is a
to be known as vitamin B2. The minimal daily groove, which lodges the corresponding inter-
requirement for an adult is 153 mg, but is costal artery and nerve.
greater during pregnancy and lactation.
Deficiency in the diet is thought to cause Rice-Water
inflammation of the substance of the cornea (see A useful diluent drink for invalids, similar to
EYE), sores on the lips, especially at the angles of barley-water.
the mouth (CHEILOSIS), and DERMATITIS. (See
APPENDIX 5: VITAMINS.) Rickets
A disease of childhood characterised chiefly by a
Ribonucleic Acid softened condition of the bones (see BONE), and
See RNA. by other evidence of poor nutrition.

Ribosome Causes This disease is the result of deficiency

Granules either found free within the cell, or of vitamin D in the diet. Healthy bones cannot
attached to a reticular network within the cells be built up without calcium (or lime) salts, and
endoplasm (the inner part of a cells cytoplasm the body cannot use these salts in the absence of
see CELLS). Consisting of approximately 65 vitamin D. Want of sunlight and fresh air in the
per cent RNA and 35 per cent PROTEIN, they are dwellings where children are reared is also of
the sites where protein is made. importance. Once a common condition in
industrial areas, it had almost disappeared in
Ribozyme Great Britain but has recurred in recent years,
Sections of deoxyribonucleic acid (DNA) the largely amongst children of Asian and African
principal molecule in a cell carrying genetic origin.
information that act as enzymes (see ENZYME). The periosteum the membrane enveloping
The function of a ribozyme is to transform the the bones becomes inflamed, and the bone
messages encoded in DNA into proteins (see formed beneath it is defective in lime salts and
PROTEIN), using its property of catalysing very soft. Changes also occur at the growing
chemical reactions in a cell. Most ribozymes act part of the bone, the epiphyseal plate.
only on other pieces of ribonucleic acid (RNA),
editing the messenger type that carries instruc- Symptoms The symptoms of rickets most
tions to the parts of the cell that makes proteins. usually appear towards the end of the first year, R
This editing ability is being used by scientists and rarely after the age of five. The children are
researching ways of correcting faulty GENES often snuffly and miserable.
which can cause inherited disorders. The aim is Gradually, changes in the shape of the bones
to persuade the ribozyme to inhibit the messen- becomes visible, first chiefly noticed at the ends
ger RNA to prevent production of the faulty of the long bones. The softened bones also tend
gene. Ribozymes might also be used to disrupt to become distorted, the legs bending outwards
infectious agents, such as viruses, which rely on and forwards so the child becomes bow-legged
RNA to invade body cells. or knock-kneed. Changes occur in the ribs
(rickets rosary) and cranial bones, while teeth
Ribs appear late and decay or fall out.
The bones, 12 on each side, which enclose the The disease usually ends in recovery with
cavity of the chest. The upper seven are joined more or less of deformity and dwarfing the
to the breast-bone by their costal cartilages and bones, although altered in shape, becoming
are therefore known as true ribs. The lower five ultimately ossified.
do not reach the breast-bone, and are therefore
known as false ribs. Of the latter, the eighth, Treatment The specific remedy is vitamin D
ninth and tenth are joined by their costal cartil- in the form of calciferol (vitamin D2). A full
ages, each one to the rib immediately above it, diet is of course essential, with emphasis upon a
 622 Rickettsia

sufficient supply of milk. Rickets is very rare in effectiveness of oral contraceptives is reduced
breast-fed children but it is a wise precaution to and alternative family-planning advice should
give breast-fed babies supplementary vitamin be offered.
D. After the child is weaned, the provision of Rifampicin should be avoided during preg-
suitable food is vital, supplemented with some nancy and breast feeding, and extra caution
source of vitamin D. Regular exposure to sun- should be applied if there is renal impairment,
light is desirable. Controversy exists as to JAUNDICE or PORPHYRIAS. Adverse effects
whether vitamin D should be added in the include gastrointestinal symptoms, influenza-
manufacture of flour, particularly of types used like symptoms, collapse and SHOCK, haemolytic
by the Asian community. ANAEMIA, acute flushing and URTICARIA; body
Deficiency of vitamin D in adults results in secretions may be coloured red.
osteomalacia (see under BONE, DISORDERS OF).
(See also APPENDIX 5: VITAMINS.) Rift Valley Fever
A virus disease, caused by a phlebovirus and
Rickettsia transmitted by mosquitoes, at one time con-
The general term given to a group of micro- fined to sub-Saharan Africa and predominantly
organisms which are intermediate between found in domestic animals such as cattle, sheep
BACTERIA and viruses (see VIRUS). They are the and goats. The only humans affected were vet-
causal agents of TYPHUS FEVER and a number of erinary surgeons, butchers and others exposed
typhus-like diseases, such as ROCKY MOUNTAIN to heavy infection by direct contact with
SPOTTED FEVER, Japanese River fever, and scrub infected animals; these usually recovered. In the
typhus. These micro-organisms are usually 1970s the disease flared up in Egypt, probably
conveyed to man by lice, fleas, ticks, and mites. owing to a more virulent virus. The illness in
humans is characterised by fever, haemorrhages,
Visceral rickettsia is a disease transmitted ENCEPHALITIS and involvement of the EYE. An
by mites from an infected house mouse, which effective vaccine protects both animals and
occurs in the USA, South Africa, Korea and the human beings against the disease (see
former Soviet Union. The causal organism is IMMUNISATION).
Rickettsia akari. The incubation period is 714
days and the characteristic features are fever, Rigidity
headache, and a non-irritating rash on the face, Stiffness, resistance to movement. The term is
trunk and extremities. The disease is non-fatal often used in NEUROLOGY for example, limb
and responds rapidly to TETRACYCLINES. rigidity is a sign of PARKINSONISM. Smooth
rigidity is described as being plastic and
Rifampicin jerky rigidity as cogwheel.
An antibiotic derived from Streptomyces medi-
terranei, rifampicin is a key component of the Rigor
treatment of TUBERCULOSIS. Like ISONIAZID, it Shivering. If prolonged, it is generally accom-
should always be included unless there is a spe- panied by fever, and may be a sign of the onset
R cific contraindication. It is also valuable in the of some acute disease such as INFLUENZA,
treatment of BRUCELLOSIS, LEGIONNAIRES DIS- PNEUMONIA, or some internal inflammation.
EASE, serious staphylococcal (see STAPHYLO- Rigor mortis is the name given to the stiffness
COCCUS) infections and LEPROSY. It is also that ensues soon after death. (See DEATH, SIGNS
given to contacts of certain forms of childhood OF; MUSCLE.)
MENINGITIS.
Rifampicin is given by mouth; during the Ring Block
first two months it often causes transient dis- A local anaesthetic agent (see ANAESTHESIA)
turbance of LIVER function, with raised concen- injected into the circumference of the base of a
trations of serum transaminases, but usually digit. It numbs the nerves of the finger or toe
treatment need not be interrupted. In patients and so permits minor surgery to be performed.
with pre-existing liver disease more severe tox- Care must be taken to avoid damage to local
icity may occur, and liver function should be blood vessels which can lead to GANGRENE.
carefully monitored both before starting and
during rifampicin treatment. It induces hepatic Ringworm
enzymes which accelerate the metabolism of Ringworm, or tinea, is the name given to
various drugs including ANTICOAGULANTS, inflammatory rashes caused by DERMATO-
SULPHONYLUREAS, PHENYTOIN SODIUM, COR- PHYTES of the genera microsporum, epidermo-
TICOSTEROIDS and OESTROGENS. The phyton and trichophyton. These fungi can
 Risk Register 623

infect skin, hair and nails. The important clin- ing, it is placed beside the ear. Normal subjects
ical patterns are: can then hear the noise once more, but in
people with conductive DEAFNESS, air conduc-
Tinea capitis Usually seen in children in tion does not persist after bone conduction has
Britain and caused by microsporum species of ceased. It can help to distinguish between nerve
human or animal (frequently a kitten) origin. (sensorineural) and conduction deafness.
Typically, patches of ALOPECIA are seen with
broken-off hair stumps which fluoresce bright Ripple Beds
green under an ultraviolet (Woods) lamp. In A development of the conventional air-beds.
Asia a chronic, scarring alopecia may be caused Their essential feature is a mattress which is
by a specific trichophyton (favus). alternately pressurised by a compressor to create
a gentle rippling effect along the entire length
Tinea corporis is usually due to trichophy- of the mattress. This provides a continuous
ton species and forms ringed (hence ring- massaging motion which stimulates the circula-
worm) patches of redness and scaling on the tion and helps to maintain the nutrition of the
trunk or limbs. skin, thereby reducing the risk of bed sores (see
ULCER Decubitus ulcer).
Tinea pedis (athletes foot) is caused by epi-
dermophyton or trichophyton species. Its Risk Factor
minor form manifests as itching, scaling or blis- An environmental or genetic factor which makes
tering in the lateral toe clefts. More severe forms the occurrence of a disease in an individual
can be extensive on the sole. Trichophyton more likely. For example, male sex, OBESITY,
rubrum can cause a chronic, dry, scaling smoking and high blood pressure (HYPERTEN-
inflammation of the foot, eventually extending SION) are all risk factors for ischaemic heart
into the nails and on to the soles and top of the disease (see under HEART, DISEASES OF).
foot which may persist for years if untreated.
Risk Management
Tinea cruris typically causes a butterfly A predictive technique for identifying potential
rash on the upper inner thighs in young adult untoward occurrences. It has been in use in cer-
males. It is usually caused by spread from the tain industries (such as nuclear power gener-
feet. ation) for many years and was introduced to the
NHS in 1991 when self-governing trusts were
Tinea unguium (onychomycosis) Af- first set up. The reasons were, firstly, that
fecting the nails, especially of the toes, T. Crown immunity had been removed from the
rubrum is the usual cause and may persist for health service in 1988, so that ceased to be
decades. immune from prosecution for non-compliance
with health and safety legislation; secondly,
Tinea barbae This rash of the face and because trusts were responsible for their own
beard is rare. It may be very inflammatory and liabilities and any consequential costs. Risk
is usually contracted from cattle by farm management starts with three simple questions: R
workers. what can go wrong?
how likely is it to happen?
Treatment Tinea of the toe clefts and groin how bad would it be if it happened?
will usually respond to an antifungal cream The combined answers allow an estimate to
containing terbinafine or an azole. Tinea capi- be made of the risk. Given the scope for clinical
tis, barbae, extensive tinea corporis and all nail mishaps in the NHS let alone staff and
infections require oral treatment with terbin- corporate risks the need for a credible, oper-
afine or itraconazole (a triazole antifungal agent ational risk strategy is substantial.
taken orally and used for candidiasis of the
mouth, throat and vulgovaginal area as well as Risk Register
for ringworm) which have largely superseded The term is used in two ways. Firstly, it may
the earlier treatment with the antiobiotic griseo- comprise a list of infants whose obstetric and/or
fulvin. (See FUNGAL AND YEAST INFECTIONS.) perinatal history suggests they might be at risk
of illness or serious abnormality such as LEARN-
Rinnes Test ING DISABILITY.
A hearing test in which a vibrating tuning fork Secondly and more commonly termed the
is placed on the mastoid process (see EAR). At-risk register this is a list held by social-
When the subject can no longer hear the ring- service departments, and accessible to doctors
 624 Risus Sardonicus

in A&E departments, of children whom a local- transports the information to the protein-
authority social-services case conference has manufacturing centres of the cell where the
deemed to have been harmed or to be at risk of information is translated from the linear
harm from mental, physical or sexual abuse (see sequence of codons in the RNA into a linear
also CHILD ABUSE). sequence of amino acids which are concurrently
converted into protein. (See also GENES.)
Risus Sardonicus
The term used for describing the facial appear- Rocky Mountain Spotted Fever
ance when the muscles of the forehead and the A fever of the typhus group (see TYPHUS FEVER).
face go into spasm in TETANUS, giving the effect It received its name from the fact that it was
of a sardonic grin. first reported in the Rocky Mountain States of
the United States; these are still the most heav-
Ritalin ily infected areas, but the fever is now found in
See METHYLPHENIDATE. all parts of the US. The causative organism is
Rickettsia rickettsi, which is transmitted to
Ritodrine humans by tics.
A beta2-adrenoceptor-stimulating drug that
relaxes uterine muscle (see UTERUS). It is used in Rodent Ulcer
selected women close to term to inhibit the A chronic form of BASAL CELL CARCINOMA, the
onset of labour for at least 48 hours. This allows most common form of skin cancer.
for the implementation of measures to improve
the perinatal health of the infant, including Rohypnol
making arrangements for transfer to a neonatal See FLUNITRAZEPAM.
intensive-care facility. (See PREGNANCY AND
LABOUR Premature birth.) Rombergism
A term applied to marked unsteadiness when a
Rivastigmine person stands with the eyes shut. It is found as a
An acetylcholinesterase inhibitor used in the symptom in some nervous diseases, such as per-
treatment of ALZHEIMERS DISEASE. Treatment ipheral NEUROPATHY and tabes dorsalis
should be under the supervision of a specialist (neurosyphilis).
and the drug should be started at a low dose
because of potential side-effects. Root Filling
Also called root-canal therapy, this is the
RNA treatment given when the nerve of a tooth (see
RNA is the abbreviation for ribonucleic acid, TEETH) has been exposed while the tooth is
one of the two types of NUCLEIC ACID that exist being prepared for a filling, or if it has died or
in nature. It is present in both the cytoplasm become infected. The nerve debris is removed
and nucleus of the CELLS of the body, but prin- and, when the chamber is clear of infection,
cipally in the former. With DNA it is an essential an inert material is inserted to seal off the
R component of the genetic code. It exists in three root.
categories known, respectively, as ribosomal (r),
transfer (t), and messenger (m) RNA. Genetic Rorschach Test
information resides in the linear sequence of A psychological test (see PSYCHOLOGY) for
nucleotides (see NUCLEIC ACID) in DNA and is investigating personality and disorders of per-
transcribed into messenger RNA before protein sonality. Also called the ink blot test, it is now
is synthesised. In the language of the computer, rarely used. It was devised by a Swiss psych-
the genetic code consists of 64 three-letter iatrist, Hermann Rorschach (18841922), who
code-words, or codons. The code in DNA is determined individuals reactions to a series of
comparable to a tape which contains informa- symmetrical ink-blots, ten in number and
tion written linearly in the form of these standardised by him.
codons, each of which is the code for one of the
20 AMINO ACIDS from which proteins are made. Rosacea
The genetic information encoded in DNA is Common chronic inflammation of the facial
used to programme the manufacture of proteins skin, this condition is seen in middle and late
(see PROTEIN) in two stages. life. Redness, obvious dilatation of venules and
In the first, the information is transcribed crops of ACNE-like papules and pustules affect
from DNA on to a molecule of mRNA. In the mainly the central forehead, cheeks, nose and
second, the messenger RNA-intermediary chin. A keratoconjunctivitis (combined
 Rubella 625

inflammation of the cornea and conjunctiva of Rouleaux

the EYE) may be associated. Subjects flush easily, The term applied to the heaps into which red
especially after alcohol or hot drinks. Eventually blood corpuscles (ERYTHROCYTES) collect as
the affected areas may become thickened and seen under the microscope.
oedematous, and in men, proliferation of
fibrous and sebaceous tissue may lead to gross Roundworms
thickening and enlargement of the nose See ASCARIASIS.
(RHINOPHYMA).
Rous Sarcoma
Treatment Long-term, low-dose, oral tetra- A malignant tumour of fowls which is caused
cycline (see ANTIBIOTICS; TETRACYCLINES) is the by a virus. This tumour has been the subject of
treatment of choice. In mild cases, METRONI- much experimental work on the nature of
DAZOLE gel can be helpful. Potent topical COR- CANCER.
TICOSTEROIDS are contraindicated and make
rosacea worse. Royal College of Nursing (RCN)
See APPENDIX 8: PROFESSIONAL ORGANISATIONS.
Roseola Infantum
A transient EXANTHEM of toddlers. Mild mal- RSI
aise is followed by a RUBELLA-like rash. It is Repetitive strain injury see UPPER LIMB
caused by herpes virus 6 (see HERPES VIRUSES). DISORDERS.

RSV
Rotator Cuff See RESPIRATORY SYNCYTIAL VIRUS (RSV).
A musculo-tendinous structure that helps to
stabilise the shoulder-joint. The cuff may be Rubella
damaged as a result of a fall; complete rupture Rubella, or German measles, is an acute infec-
requires surgical treatment and intensive tious disease of a mild type, which may some-
PHYSIOTHERAPY.
times be difficult to differentiate from mild
forms of MEASLES and SCARLET FEVER.
Rotaviruses
A group of viruses (so-called because of their Cause A virus spread by close contact with
wheel-like structure: rota is Latin for wheel) infected individuals. Rubella is infectious for a
which are a common cause of GASTROENTERI- week before the rash appears and at least four
TIS in infants (see also DIARRHOEA). They cause days afterwards. It occurs in epidemics (see EPI-
from 25 to 80 per cent of childhood diarrhoea DEMIC) every three years or so, predominantly
in different parts of the world, and in the in the winter and spring. Children are more
United Kingdom they are responsible for 60 likely to be affected than infants. One attack
65 per cent of cases. They infect only the cells gives permanent IMMUNITY. The incubation
lining the small intestine. In the UK, death period is usually 1421 days.
from rotavirus is rare. R
Symptoms are very mild, and the disease is
Roughage not at all serious. On the day of onset there may
Dietary fibre is that part of food which cannot be shivering, headache, slight CATARRH with
be digested in the gastrointestinal tract, sneezing, coughing and sore throat, with very
although it can be metabolised in the colon by slight fever not above 378 C (100 F). At
the micro-organisms there. Roughage falls into the same time the glands of the neck become
four groups: cellulose, hemicelluloses, lignins enlarged. Within 24 hours of the onset a pink,
and pectins, found in unrefined foods such as slightly raised eruption appears, first on the face
wholemeal cereals and flour, root vegetables, or neck, then on the chest, and the second day
nuts and fruit. It has long been known to affect spreads all over the body. The clinical signs and
bowel function, probably because of its capacity symptoms of many other viral infections are
to hold water in a gel-like form. It plays an indistinguishable from rubella so a precise
important role in the prevention of CONSTIPA- diagnosis cannot be made without taking sam-
TION, DIVERTICULOSIS, IRRITABLE BOWEL SYN- ples (such as saliva) for antibody testing, but
DROME (IBS), APPENDICITIS, DIABETES MELLITUS this is rarely done in practice.
and cancer of the colon (see INTESTINE). At An attack of German measles during the
present, many western diets do not contain early months of pregnancy may be responsible
enough roughage. for CONGENITAL defects in the FETUS (for
 626 Rupture

information on fetal abnormalities, see under pregnancy, any pregnant mother exposed to
PREGNANCY AND LABOUR). The incidence of infection during this period should be given an
such defects is not precisely known, but prob- intramuscular injection of GAMMA-GLOBULIN.
ably around 20 per cent of children whose A vaccine is available to protect an individual
mothers have had German measles in the first against rubella (see IMMUNISATION).
three months of the pregnancy are born with In the United Kingdom it is NHS policy for
congenital defects. These defects take a variety all children to have the combined measles,
of forms, but the most important ones are: low mumps and rubella vaccine (see MMR VACCINE),
birth weight with retarded physical develop- subject to parental consent. All women of
ment; malformations of the HEART; cataract (see childbearing age, who have been shown by a
under EYE, DISORDERS OF); and DEAFNESS. simple laboratory test not to have had the dis-
ease, should be vaccinated, provided that the
Treatment There is no specific treatment. woman is not pregnant at the time and has not
Children who develop the disease should not been exposed to the risk of pregnancy during
return to school until they have recovered, and the previous eight weeks.
in any case not before four days have passed
from the onset of the rash. Rupture
In view of the possible dangerous effect of A popular name for HERNIA.
the disease upon the fetus, particular care
should be taken to isolate pregnant mothers Ryles Tube
from contact with infected subjects. As the risk See NASOGASTRIC TUBE.
is particularly high during the first 16 weeks of

R
 back and buttocks. Such strains may take a long

S time to mend; PHYSIOTHERAPY is the treat-

ment. The joint(s) may become inflamed (see
SACROILEITIS).

Sacrum
The portion of the SPINAL COLUMN near its
Sabin Vaccine lower end. The sacrum consists of five vertebrae
Introduced in 1962, the attenuated live oral fused together to form a broad triangular bone
vaccine (Sabin) against POLIOMYELITIS replaced which lies between the two haunch-bones and
the previous inactivated vaccine introduced in forms the back wall of the pelvis.
1956 (see SALK VACCINE).
Sadism
Saccharine The term applied to a form of sexual perver-
A sweetening agent that is 400 times as sweet as sion, in which satisfaction is derived from the
cane sugar, but with no energy content. Apart infliction of cruelty upon another person. The
from its rather bitter aftertaste, it has practically condition is commoner in men than in women
no effect on the tissues, and escapes from the and is sometimes linked with MASOCHISM (a
body unchanged. Destroyed by heat, saccharine wish to be hurt or abused).
is not used in cooking, but is an important
component of all diabetic and low-calorie diets. Safe Period
That period during the menstrual cycle (see
Saccharomyces MENSTRUATION) when fertilisation of the
Another name for YEAST. OVUM is unlikely to occur. OVULATION usually
occurs about 15 days before the onset of the
Sacral Nerves menstrual period. A woman is commonly
The five pairs of spinal nerves that leave the believed to be fertile for about 11 days in each
SPINAL COLUMN in the sacral area. They carry menstrual cycle in other words, on the day of
motor and sensory fibres from the anal and ovulation and for five days before and five days
genital regions and from both legs. after this; this would be the eighth to the 18th
day of the usual 28-day menstrual cycle. Out-
Sacral Vertebrae side this fertile period is the SAFE PERIOD: the
The five fused vertebrae that link the thoracic first week and the last ten days of the menstrual
spine and the coccyx and form the sacrum (see cycle. On the other hand, there is increasing
SPINAL COLUMN). evidence that the safest period is the last few
days before menstruation. In the case of irregu-
Sacroileitis lar menstruation it is not possible to calculate
(See SACROILIAC JOINT.) Inflammation of one or the safe period. In any event, the safety is not
both sacroiliac joints, which lie between the absolute. (See also CONTRACEPTION.)
sacrum and the iliac bones. The condition may
be the result of RHEUMATOID ARTHRITIS, anky- Safety of Drugs
losing spondylitis (see under SPINE AND SPINAL The COMMITTEE ON SAFETY OF MEDICINES
CORD, DISEASES AND INJURIES OF), REITERS (CSM) has the function of scrutinising the effi-
SYNDROME, or the arthritis that occurs with cacy, quality and safety of new DRUGS before
PSORIASIS or infection. Sacroileitis causes pain clinical trials and before marketing, as well as
in the lower back, buttocks, thighs, and groin. the surveillance of each drug after marketing so
Stiffness may occur with ankylosing spondyl- that adverse reactions are monitored and
itis. NON-STEROIDAL ANTI-INFLAMMATORY documented, and warnings issued as required.
DRUGS (NSAIDS) relieve the symptoms. If the Early clinical trials of a drug can only be carried
cause is infection, antibiotics should be used. out after a clinical-trial certificate has been
issued by the licensing authority.
Sacroiliac Joint The major defect in this system is the dif-
One of a pair of joints between each side of the ficulty in obtaining reports of adverse reactions.
SACRUM and each ILIUM. Strong ligaments Evidence suggests that at most, about 10 per
between the ilium and the sacrum stabilise the cent of such reactions are reported. One
joint, permitting little movement. Childbirth method of trying to obtain this information is
or strenuous sporting activities may strain the the yellow card system. It is so called because it
joint, causing pain in the lower part of the is based on the distribution of yellow cards to all
 628 Sagittal

doctors, pharmacists and dentists, on which Saliva

they are asked to report any adverse reaction The fluid secreted by the SALIVARY GLANDS into
happening to someone taking a drug, whether the mouth. The ingestion of food stimulates
or not they think it is the cause. Alternatively saliva production. Saliva contains mucus and an
the CSM has a Freephone line and on-line ENZYME known as PTYALIN, which changes
computer facilities (ADROIT) for practitioners starch into dextrose and maltose (see DIGES-
to use. Even though the annual number of TION); also many cells of different types. About
adverse reactions reported in this way has risen 750 millilitres are produced daily.
from around 5,000 in 1975 to more than The principal function of saliva is to aid in
18,000, this is probably fewer than the number the initial processes of digestion, and it is essen-
actually occurring. tial for the process of mastication (chewing),
Two further committees in this safety screen whereby food is reduced to an homogeneous
are the Joint Committee on Vaccination and mass before being swallowed. In addition, the
Immunisation and the Adverse Reactions to ptyalin in the saliva initiates the digestion of
Vaccines and Immunological Substances starch in the food.
Committee. An excessive flow of saliva known as saliva-
tion occurs as the result of taking certain drugs.
Sagittal Salivation also occurs as the result of irritation
The term applied to a structure or section run- in the mouth as for instance, in the teething
ning from front to back in the body. child and from DYSPEPSIA. Deficiency of saliva
is known as XEROSTOMIA.
Salaam Attacks
See INFANTILE SPASMS.
Salivary Glands
The glands (see GLAND) situated near, and open-
Salbutamol ing into, the cavity of the mouth, by which the
A short-acting selective beta2-adrenoceptor SALIVA is manufactured. They include the par-
stimulant delivered via a metered-dose aerosol otid gland, placed in the deep space that lies
inhaler, a powder inhaler or through a nebuliser between the ear and the angle of the jaw; the
to control symptoms of ASTHMA. If stimulant submandibular gland, lying beneath the hori-
inhalation is needed more than twice a day to zontal part of the jaw-bone; and the sublingual
control asthma attacks, prophylactic treatment gland, which lies beneath the tongue.
should be considered including, in severe cases, Each gland is made up of branching tubes
oral CORTICOSTEROIDS. Salbutamol relaxes the closely packed together, and supported by
muscles which cause bronchial spasms in the strong connective tissue. These tubes are lined
lungs the prime symptom of asthma. There by large cells that secrete the saliva, and ducts
are other similar preparations such as transfer the saliva to openings in the mouth.
terbutaline. The parotid gland secretes a clear fluid contain-
ing the ENZYME, PTYALIN; in the sublingual
Salicylic Acid gland they mainly produce mucus, whilst the
A crystalline substance sparingly soluble in submandibular gland contains cells of both
water that is used externally in ointments and types.
S pastes. It has antifungal properties and helps to
loosen and remove scales. In high concentra-
tions it is useful in treatment of verrucae Salk Vaccine
(WARTS) and corns (see CORNS AND BUNIONS). A vaccine obtained by treating the POLIOMYEL-
ITIS virus with formalin. This prevents the virus

Saline from causing the disease but allows it to stimu-

Normal saline is a solution containing 09 per late the production of ANTIBODIES. Salk vac-
cent of sodium chloride (common salt). Saline cine is given by injection and protects the
is used clinically to dilute drugs given by injec- recipient against the disease. (See also
IMMUNISATION.)
tion; it is also given as an intravenous infusion
to restore blood volume if blood loss from acci-
dent or operation is not too serious, or to tide a Salmonella Infections
patient over until PLASMA or blood for TRANS- See FOOD POISONING; ENTERIC FEVER;
FUSION becomes available. DYSENTERY.
Saline is also given orally to severely
dehydrated children or adults suffering from Salmon Patches
diarrhoea and, in particular, CHOLERA. See NAEVUS Naevus simplex.
 Saphenous 629

Cutaway diagram of left side of face showing position of salivary glands in relation to tongue and
lower jaw.

Salpingitis of a small hairy midge or sandfly (Phlebotomus

Inflammation situated in the FALLOPIAN TUBES; papatasi). The incubation period is 37 days.
these run from the OVARIES to the UTERUS and
carry the ova or eggs. The disorder is commonly Symptoms There are headache, feverishness,
caused by infection spreading upwards from the general sensations like those of INFLUENZA,
VAGINA, cervix or uterus. It is one feature of flushed face and bloodshot eyes, but no signs of
PELVIC INFLAMMATORY DISEASE (PID). Salpin- CATARRH. The fever passes off in three days, but
gitis is potentially serious and requires treat- the patient may take some time to convalesce.
ment with antibiotics and sometimes surgery to
drain any PUS or, in persistent infections, to Treatment As there is no specific remedy,
remove the Fallopian tubes. PROPHYLAXIS is important. This consists of the
spraying of rooms with an insecticide such as
Salpingo- GAMMEXANE; the application of insect repel-
A prefix indicating a connection with either the lents such as dimethyl phthalate to the exposed
FALLOPIAN TUBES or the EUSTACHIAN TUBES. parts of the body (e.g. ankles, wrists and face),
particularly at sunset; and the use of sandfly
Salpingography nets at night. Once the infection is acquired,
Radiography (see X-RAYS) of one or both FAL- treatment consists of rest in bed, light diet and
LOPIAN TUBES after radio-opaque material has aspirin and codeine.
been injected into them via the UTERUS.
Sanguineous
Salpingo-Ophorectomy This term means containing blood.
Surgical removal of a Fallopian tube (see FAL-
LOPIAN TUBES) and its accompanying ovary (see Sanitary Protection S
OVARIES). Disposable sanitary towels or tampons (see
TAMPON) used to protect clothing from blood-
Salt stains during MENSTRUATION. They are avail-
The substance produced by the replacement of able in different absorbencies to meet womens
the acidic hydrogen of an acid by a metal or individual needs.
basic radical. It is also a synonym for common
salt or sodium chloride. Sodium chloride is a Saphenous
vital constituent of cells, and a proper balance The name given to the two large superficial
between it and other salts in the cells and body veins of the leg. The small saphenous vein,
tissues is important for their viability. which runs up the outside and back of the leg,
joins the deep veins at the bend of the knee; the
Sandfly Fever great saphenous vein the longest vein in the
This is a short, sharp fever occurring in many body, which has a course from the inner ankle
parts of the tropics and subtropics, including to the groin is especially subject, with its
most of the Mediterranean littoral. It is due to a branches, to become the site of VARICOSE
virus, called phlebovirus, conveyed by the bite VEINS.
 630 Saprophyte

Saprophyte areas. It is composed of FIBRIN, which is exuded

An organism which lives usually upon decaying from the raw surface, together with blood cor-
and dead matter and produces its puscles and epithelial cells entangled in its
decomposition. meshes. Healing takes place naturally under this
protection, and the scab dries up and falls off
Sarco- when healing is complete. Scabs appearing on
A prefix signifying flesh or fleshy. the face without any previous abrasion are
usually caused by an infection (see IMPETIGO).
Sarcoidosis
An uncommon chronic inflammatory disease of Scabicide
unknown origin which can affect many organs, A drug that eliminates the mites which cause
particularly the SKIN, eyes (see EYE) and LUNGS. SCABIES.
Commonly, it presents as ERYTHEMA nodosum
in association with lymph-gland enlargement Scabies
within the chest. In the eyes it causes UVEITIS. A common contagious itching disease caused
BIOPSY of affected tissue allows diagnosis, which by Sarcoptes scabei hominis (see SARCOPTES)
is confirmed by a KVEIM TEST. Often sarcoido- which can live only on human skin. The fertil-
sis is self-limiting, but in severe cases oral COR- ised female burrows into the skin surface, creat-
TICOSTEROIDS may be needed. ing a tunnel within the stratum corneum in
which she deposits 23 eggs per day, as well as
Sarcoma faecal pellets which contain the ALLERGEN
See CANCER. which initiates the immune reaction respon-
sible for symptoms. The adult female is just
Sarcoptes visible. Eggs hatch within 34 days, producing
Mites which infest humans and animals. Sar- larvae. After successive moults these become
coptes scabei hominis causes human SCABIES. adult mites and the 15-day lifecycle re-starts. A
Other species infest dogs (sarcoptic mange), rapid build-up of mite numbers is not noticed
cats and birds. by the host until an immune response induces
itching after about six weeks. Subsequently,
SARS scratching reduces the adult mites to a dozen or
In 2003, an outbreak occurred of a previously fewer. Scabies is spread by skin-to-skin contact,
unrecognised illness termed SARS, or severe usually via the hands: it thus spreads in a family
acute respiratory syndrome. It was caused by or sexual setting. Though most common in
infection with a newly identified coronavirus, young adults, scabies can affect any age-group.
SARS-COV. Infection produced an illness with Typically the patient complains of wide-
PNEUMONIA as a prominent feature, but some spread severe itching, worse when the body is
patients developed other events such as loss of warm after a bath or in bed. Burrows are visible
appetite, diarrhoea and bleeding from the as wavy black lines 35 mm long in the skin of
stomach. Many of those who developed the the hands, wrists or sides of the feet. The inten-
disease were health-care workers and the con- sity of the rash depends on the immune
tagion rate was vey high. response. Papules, pustules, crusts and excori-
S Exceptional isolation procedures became ations are seen on the hands and there may be a
necessary as the EPIDEMIC threatened to spread widespread eczematous (see DERMATITIS) or
worldwide from its origin in Hong Kong. For urticarial (see URTICARIA) rash elsewhere. Pap-
example, patients were concentrated in indi- ules or even nodules on the PENIS and SCRO-
vidual hospitals which were turned into isol- TUM are characteristic. In infants, burrows
ation units with a no visiting policy. Staff and occur on the palms and soles. Diminished
other patients exposed to those with the disease immune response in old age, DOWNS (DOWN)
were quarantined (see QUARANTINE) in the spe- SYNDROME, etc. lead to a type of scabies which
cial units. All non-urgent hospital inpatient is less itching and more scaly. Rarely, absence of
care was cancelled, and potential contacts were immune response causes a mite-saturated, gen-
closely screened. Travel restrictions were put in eralised scaly dermatitis (Norwegian scabies).
place. These measures, coordinated by the Admission of such a patient to hospital may
World Health Organisation, brought the epi- result in an outbreak of scabies in other
demic under control. patients, staff and visitors caused by mite-
infested airborne scale.
Scab
The crust which forms on superficial injured Treatment MALATHION 05 per cent aqueous
 Scarlet Fever 631

lotion, or PERMETHRIN 5 per cent cream, some structures than others, and a pattern of
applied to the whole body, except the head, for those reflections is detected and shown on a
24 hours and then washed off cures the infec- screen. Other screening methods include
tion. In infants the head and neck should be COMPUTED TOMOGRAPHY, magnetic reson-
included. The secondary eruption may take 2 ance imaging (MRI), positron emission tom-
3 weeks to settle completely and 10 per cent ography (PET SCANNING) and RADIONUCLIDE
crotamiton cream is used during this period. It scanning, which measures the differential
is essential that all intimate contacts be treated uptake of radioactive materials in the bodys
simultaneously. FOMITES need not be treated. tissues.

Scalded-Skin Syndrome Scaphoid Bone

In infants, certain staphylococcal bacteria (see The outside bone on the thumb side of the
STAPHYLOCOCCUS) can cause an acute toxic ill- HAND in the row of carpal (wrist) bones nearest
ness in which the subject develops sheets of to the forearm. Fracture of the scaphoid is a
bright ERYTHEMA, accompanied by shedding of common wrist injury that usually occurs when
layers of outer epidermis. The result is similar someone falls on to their outstretched hand.
to a hot-water scald. The condition responds The fracture may not be diagnosed at first (even
promptly to appropriate antibiotic therapy. an X-ray may not be abnormal). Pain in and
Drug reactions, especially from sulphonamides, permanent damage to the wrist can occur.
may cause a similar syndrome in adults. In
drug-induced forms, mucosae are also affected Scapula
and the disease is often fatal. The scientific name for the shoulder-blade. (See
SHOULDER.)
Scalds
See BURNS AND SCALDS. Scar
The name applied to a healed wound, ulcer or
Scalp breach of tissue. A scar consists essentially of
The soft covering of the SKULL on the top of the fibrous tissue, covered by an imperfect forma-
head. It consists of five layers, which from the tion of epidermis in the case of scars on the
surface inwards are as follows: the skin, from surface of the skin. The fibrous tissue is pro-
which grows hair; next a subcutaneous layer of duced by the connective tissue that migrates to
fat; thirdly, a tough fibrous membrane known the wound in the course of its repair (see
as the epicranium; fourthly, a loose layer of WOUNDS). Gradually this fibrous tissue con-
connective tissue attaching the epicranium to tracts, becomes more dense, and loses its blood
the deepest layer, and permitting the free vessels, leaving a hard white scar. (See also
movement of the scalp; and, finally, another KELOID.)
fibrous layer clinging closely to the skull, and
known as the pericranium. Scarlet Fever
This disorder is caused by the erythrogenic
Scalpel toxin of the STREPTOCOCCUS. The symptoms
A small, straight, surgical knife. of PYREXIA, headache, vomiting and a punctate
erythematous rash (see ERYTHEMA) follow a S
Scanning Speech streptococcal infection of the throat or even a
A speech disorder in which articulated syllables wound. The rash is symmetrical and does not
are wrongly spaced and each is given the same itch. The skin subsequently peels.
vocal emphasis. The condition occurs as a result
of disease in the cerebellum (see BRAIN) or its Symptoms The period of incubation (i.e. the
connecting nerves. (See also VOICE AND SPEECH.) time elapsing between the reception of infec-
tion and the development of symptoms) varies
Scanning Techniques somewhat. In most cases it lasts only two to
Ways of producing images of body organs that three days, but in occasional cases the patient
record, process and analyse sound waves, radio may take a week to develop his or her first
waves or X-RAYS passing through or generated symptoms. The occurrence of fever is usually
by the bodys tissues. ULTRASOUND scanning short and sharp, with rapid rise of temperature
using high-frequency, inaudible sound waves to 40 C (104 F), shivering, vomiting, head-
directed at the area of the body being studied ache, sore throat and marked increase in the
is the most generally used scanning procedure. rate of the pulse. In young children, CONVUL-
Sound waves are reflected more powerfully by SIONS or DELIRIUM may precede the fever. The
 632 Schistomicide

rash usually appears within 24 hours of the cellular function is preserved until late in the
onset of fever and lasts about a week. disease. S. japonicum (which is confined to the
Far East, especially Indonesia) behaves similarly
Complications The most common and ser- to S. mansoni infection; liver involvement is
ious of these is glomerulonephritis (see under often more severe.
KIDNEYS, DISEASES OF), which may arise during Diagnosis can be made by microscopic exam-
any period in the course of the fever, but par- ination of URINE or FAECES. The characteristic
ticularly when DESQUAMATION occurs. eggs are usually detectable. Alternatively, rectal
Occasionally the patient develops chronic or liver BIOPSY are of value. Serological tests,
glomerulonephritis. Another complication is including an ELISA (see ENZYME-LINKED
infection of the middle ear (otitis media see IMMUNOSORBENT ASSAY (ELISA)), have now
under EAR, DISEASES OF). Other disorders affect- largely replaced invasive procedures used in
ing the heart and lungs occasionally arise in making a parasitological diagnosis.
connection with scarlet fever, the chief of these
being ENDOCARDITIS, which may lay the foun- Treatment CHEMOTHERAPY has been revo-
dation of valvular disease of the heart later in lutionised by the introduction of praziquantel
life. ARTHRITIS may produce swelling and pain (administered orally); this compound has no
in the smaller rather than in the larger joints; serious side-effects, although its cost may limit
this complication usually occurs in the second its use in developing countries. Oxamniquine is
week of illness. Scarlet fever, which is now a cheaper and effective in S. mansoni infection,
mild disease in most patients, should be treated although evidence of resistance has been
with PENICILLIN. recorded in several countries. Metriphonate is
also relatively cheap and is of value in S. haema-
Schistomicide tobium infection. Prevention is by complete
A drug used to treat SCHISTOSOMIASIS. Prazi- avoidance of exposure to contaminated water;
quantel is the drug of choice, with a combin- all travellers to infected areas should know
ation of effectiveness, broad-activity spectrum about this disease. It is increasing in frequency
and few side-effects. as new expanses of fresh water appear as a result
of irrigation schemes and dam projects. Mol-
Schistosomiasis luscicides can be employed for snail-control.
Also known as BILHARZIASIS. This infection
results from one of the human Schistosoma spe- Schizo-
cies. It is common in Africa, South America, the A prefix signifying splitting.
Far East, Middle East, and, to a limited extent, Schizogony
the Caribbean. The life-cycle is dependent on An asexual phase in the life-cycle of a sporozoan
fresh-water snails which act as the intermediate (see SPOROZOA) that occurs in red blood cells or
host for the fluke; the cercarial stage of the fluke liver cells.
enters via intact human skin and matures in the
portal circulation. Clinically, swimmers itch Schizophrenia
may occur at the site of cercarial skin penetra- An overall title for a group of psychiatric dis-
tion. Acute schistosomiasis (Katayama fever) orders typfied by disturbances in thinking,
S can result in fever, an urticarial rash (see URTI- behaviour and emotional response. Despite its
CARIA), and enlargement of LIVER and SPLEEN. inaccurate colloquial description as split per-
The adult male is about 12 mm and the female sonality, schizophrenia should not be confused
24 mm in length. with MULTIPLE PERSONALITY DISORDER. The
S. haematobium causes CYSTITIS and haem- illness is disabling, running a protracted course
aturia passage of blood in the urine; bladder that usually results in ill-health and, often, per-
cancer and ureteric obstruction, giving rise to sonality change. Schizophrenia is really a collec-
hydronephrosis and kidney failure, are long- tion of symptoms and signs, but there is no
term sequelae in a severe case. S. mansoni can specific diagnostic test for it. Similarity in the
cause colonic symptoms and in a severe case, early stages to other mental disorders, such as
POLYPOSIS of the COLON; diarrhoea, which may MANIC DEPRESSION, means that the diagnosis
be bloody, can be a presenting feature. In a may not be confirmed until its response to
heavy infection, eggs surrounded by granulo- treatment and its outcome can be assessed and
mas are deposited in the liver, giving rise to other diseases excluded.
extensive damage (pipe-stem fibrosis) associated
with PORTAL HYPERTENSION, oesophageal vari- Causes There is an inherited element: par-
ces, etc. However, unlike in CIRRHOSIS, hepato- ents, children or siblings of schizophrenic
 Sciatica 633

sufferers have a one in ten chance of developing very important that patients take them indefin-
the disorder; a twin has a 50 per cent chance if itely. This is easier to ensure when a patient is in
the other twin has schizophrenia. Some BRAIN hospital or in a stable domestic environment.
disorders such as temporal lobe EPILEPSY, CLOZAPINE a newer, atypical antipsychotic
tumours and ENCEPHALITIS seem to be linked drug is used for treating schizophrenic
with schizophrenia. Certain drugs for patients unresponsive to, or intolerant of, con-
example, AMPHETAMINES can precipitate ventional antipsychotics. It may cause AGRANU-
schizophrenia and DOPAMINE-blocking drugs LOCYTOSIS and use is confined to patients regis-
often relieve schizophrenic symptoms. Stress tered with the Clorazil (the drugs registered
may worsen schizophrenia and recreational name) Patient Monitoring Service. Amisul-
drugs may trigger an attack. pride, olanzapine, quetiapine, risperidone,
sertindole and zotepine are other antipsychotic
Symptoms These usually develop gradually drugs described as atypical by the British
until the individuals behaviour becomes so National Formulary; they may be better toler-
distrubing or debilitating that work, relation- ated than other antipsychotics, and their vary-
ships and basic activities such as eating and ing properties mean that they can be targeted at
sleeping are interrupted. The patient may have patients with a particular grouping of symp-
disturbed perception with auditory HALLUCIN- toms. They should, however, be used with
ATIONS, illogical thought-processes and DELU- caution.
SIONS; low-key emotions (flat affect); a sense The welcome long-term shift of mentally ill
of being invaded or controlled by outside patients from large hospitals to community care
forces; a lack of INSIGHT and inability to (often in small units) has, because of a lack of
acknowledge reality; lethargy and/or agitation; resources, led to some schizophrenic patients
a disrespect for personal appearance and not being properly supervised with the result
hygiene; and a tendency to act strangely. Vio- that they fail to take their medication regularly.
lence is rare although some sufferers commit This leads to a recurrence of symptoms and
violent acts which they believe their inner there have been occasional episodes of such
voices have commanded. patients in community care becoming a danger
Relatives and friends may try to cope with to themselves and to the public.
the affected person at home, but as severe epi- The antipsychotic drugs are powerful agents
sodes may last several months and require regu- and have a range of potentially troubling side-
lar administration of powerful drugs patients effects. These include blurred vision, constipa-
are not always good at taking their medication tion, dizziness, dry mouth, limb restlessness,
hospital admission may be necessary. shaking, stiffness, weight gain, and in the long
term, TARDIVE DYSKINESIA (abnormal move-
Treatment So far there is no cure for schizo- ments and walking) which affects about 20 per
phrenia. Since the 1950s, however, a group of cent of those under treatment. Some drugs can
drugs called antipsychotics also described as be given by long-term depot injection: these
NEUROLEPTICS or major tranquillisers have include compounds of flupenthixol, zuclopen-
relieved florid symptoms such as thought dis- thixol and haloperidol.
order, hallucinations and delusions as well as
preventing relapses, thus allowing many people Prognosis About 25 per cent of sufferers S
to leave psychiatric hospitals and live more recover fully from their first attack. Another 25
independently outside. Only some of these per cent are disabled by chronic schizophrenia,
drugs have a tranquillising effect, but their seda- never recover and are unable to live independ-
tive properties can calm patients with an acute ently. The remainder are between these
attack. CHLORPROMAZINE is one such drug and extremes. There is a high risk of suicide.
is commonly used when treatment starts or to
deal with an emergency. Halperidol, trifluo- Schwann Cell
perazine and pimozide are other drugs in the The cells that produce the MYELIN sheath of the
group; these have less sedative effects so are AXON of a medullated NERVE. They are
useful in treating those whose prominent wrapped around a segment of the axon, form-
symptoms are apathy and lethargy. ing concentric layers.
The antipsychotics mode of action is by
blocking the activity of DOPAMINE, the chem- Sciatica
ical messenger in the brain that is faulty in Pain in the distribution of the sciatic nerve. It is
schizophrenia. The drugs quicken the onset and often accompanied by pain in the back, or
prolong the remission of the disorder, and it is LUMBAGO. In the majority of cases, however, it
 634 Scirrhus

is due to a PROLAPSED INTERVERTEBRAL DISC in applied to conditions in which portions of

the lower part of the SPINAL CORD. What prob- organs harden and lose their function as the
ably happens is that degenerative changes take result of an excessive production of CONNECT-
place in the annulus fibrosus (see SPINAL COL- IVE TISSUE. The term is especially applied to a
UMN) as a result of some special strain caused, change of this type taking place in the nervous
for example, by heavy lifting or spon- system. (See MULTIPLE SCLEROSIS (MS)).
taneously. The cushioning disc between the two
neighbouring vertebral bodies slips through the Sclerotherapy
rent in the annulus fibrosus, and presses on the A treatment that involves injecting varicose
neighbouring roots, thus causing the pain. The veins (see VEINS, DISEASES OF) with a sclerosing
precise distribution of the pain will thus depend fluid. This causes fibrosis of the lining of the
on which of the nerve roots are affected. As a vein and its eventual obliteration. Sclerotherapy
rule, the pain is felt in the buttock, the back of is also used to treat varicose veins in the legs,
the thigh and the outside and front of the leg, anus (HAEMORRHOIDS) and at the junction of
sometimes extending on to the top of the foot, the OESOPHAGUS with the stomach.
the back of the thigh and the calf, and then
along the outer border of the foot towards the Scoliosis
little toe. The name applied to curvature of the spine. (See
Rare causes include a tumour in the spine or SPINE AND SPINAL CORD, DISEASES AND INJUR-
spinal column, tuberculosis of the spine, anky- IES OF.)
losing spondylitis (see SPINE AND SPINAL CORD,
DISEASES AND INJURIES OF) or a tumour in one
Scorbutic
This is an adjective characterising SCURVY; typ-
of the organs in the pelvis such as the UTERUS.
ically swollen, spongy gums that bleed easily,
and spontaneous haemorrhages and bruising
Treatment consists essentially of rest in bed anywhere in the body.
in the early stages until the acute phase is over.
ANALGESICS, such as aspirin and codeine, are
Scotoma
given to relieve the pain. Expert opinion varies An area of blindness in the field of vision.
as to the desirability of wearing a PLASTER OF
PARIS jacket or a specially made corset; also, as Screening Test
to the desirability of manipulation of the spine The screening of apparently healthy people to
and operation. Surgeons are selective about identify those who may have treatable diseases.
which patients might benefit from a LAMINEC- Cervical smears are done when screening
TOMY (removal of the protruding disc). women to detect if they have cancer or precan-
cer of the neck of the womb (cervix). Newborn
Scirrhus babies are screened for hip dislocation. Screen-
A hard form of cancer containing fibrous tissue. ing tests are not designed to diagnose individual
persons, but rather to divide a population into a
Sclera large number at low risk and a small number at
See EYE. high risk of a condition. This allows clinicians
to concentrate on a sub-section of the popula-
S Scleritis tion. All screening tests produce false negative
See under EYE, DISORDERS OF. and false positive results, a problem often mis-
understood by those at the receiving end. Fac-
Scleroderma tors to be assessed when planning screening
A rare autoimmune disease. Scleroderma cir- procedures include the severity, frequency and
cumscriptum (morphoea) affects the skin, usu- distribution of the disease, and the availability
ally of the trunk, producing indurated plaques and effectiveness of treatment. Convenience,
which resolve over many years. The more ser- safety, sensitivity and cost should also be
ious systemic form of scleroderma usually assessed. In the United Kingdom the govern-
begins with RAYNAUDS DISEASE, eventually ment has supported the extension of screening
producing a deforming hardening and clawing procedures for breast cancer, cervical cancer,
of the hands. Later the face and sometimes the hypertension and diabetes. (See PREVENTIVE
internal organs, particularly the gastrointestinal MEDICINE.)
tract and kidneys, may be affected.
Scriveners Palsy
Sclerosis Another name for writers cramp (see MUSCLES,
This term means literally hardening, and is DISORDERS OF).
 Sebum 635

Scrofula vitamin C (ascorbic acid see APPENDIX 5: VIT-

This is a traditional term for TUBERCULOSIS of AMINS) and is now rarely seen in developed
the lymph glands in the neck. It was formerly countries except in people on poor diets, such
known in England as kings evil, from the as homeless down-and-outs. Ascorbic acid is a
belief that the touch of the sovereign could water-soluble vitamin derived from citrus
effect a cure. This superstition can be traced fruits, potatoes and green vegetables. Nowadays
back to the time of Edward the Confessor in woody haemorrhagic OEDEMA of the legs is the
England, and to a much earlier period in usual way in which the disease presents. The
France. The disease, which is treated with former classic disease of sailors living on salt
antituberculous drugs, is now rare in developed beef and biscuits was characterised by bleeding
societies and usually affects young children. of the gums, loss of teeth, haemorrhage into
joints, ANAEMIA, lethargy and DEPRESSION. The
Scrombotoxin Poisoning introduction of fresh lime juice into the sea-
This occurs from eating poorly preserved mans diet in 1795 eliminated scurvy in the
scromboid fish such as tuna, mackerel and Royal Navy. Vitamin C is curative.
other members of the mackerel family. In such
fish, a toxic histamine-like substance is pro- Sea-Sickness
duced by the action of bacteria or histidine, a See MOTION (TRAVEL) SICKNESS.
normal component of fish flesh. This toxin
produces nausea, vomiting, headache, upper Seasonal Affective Disorder
abdominal pain, difficulty in swallowing, thirst, Syndrome
itching and sometimes URTICARIA. The condi- Known colloquially as SADS, this is a disorder
tion settles as a rule in 12 hours. ANTI- in which an affected individuals mood
HISTAMINE DRUGS sometimes ameliorate the changes with the seasons. He or she is com-
condition. monly depressed in winter, picking up again
in the spring. The diagnosis is controversial
Scrotum and its prevalence is not known. The mood-
The pouch of skin and fibrous tissue, posi- change is probably related to light, with
tioned outside the abdomen behind the root of MELATONIN playing a key role. (See also MEN-
the PENIS, within which the testicles (see TES- TAL ILLNESS.)
TICLE) are suspended. It consists of a purse-like
fold of skin, within which each testicle has a Sebaceous Cyst
separate investment of muscle fibres, several A misnomer applied to epidermoid cysts of the
layers of fibrous tissue, and a serous membrane skin whose contents are kerateous not
known as the tunica vaginalis. The extra- sebaceous. The common wen of the scalp
abdominal site means that the production and arises from follicular epithelium and is similar.
storage of sperm (see SPERMATOZOON) in the
testicles is at a lower temperature than internal Sebaceous Glands
body heat. Temperature control is facilitated by The minute glands situated alongside hairs
contraction and relaxation of the scrotal and opening into the follicles of the latter a
muscles. short distance below the point at which the
hairs emerge on the surface. These glands S
Scrum-Pox secrete an oily material, and are especially large
A popular name for a contagious condition of upon the nose, where their openings form pits
the face affecting rugby football players. It is that are easily visible. In the mouth the glands
most likely to occur in forwards as a result of open directly on the mucosal surface. (See also
face-to-face contact with individuals with the SKIN.)
infection in the opposing side of the scrum.
Other possible sources of infection are changing Seborrhoea
rooms and communal baths. The condition Excessive production of SEBUM; it occurs in
may take the form of IMPETIGO or HERPES ACNE vulgaris.
SIMPLEX.
Sebum
Scurf The secretion of the SEBACEOUS GLANDS. It acts
See DANDRUFF. as a natural lubricant of the hair and skin and
protects the skin from the effects of moisture or
Scurvy excessive dryness. It may also have antibacterial
Scurvy, or scorbitus, is caused by deficiency of action.
 636 Secondary Prevention

Secondary Prevention aggressive behaviour under control. Sedation is

The early detection of disease that reduces or also a part of the preparation of a patient for
prevents its serious outcome. Routine regular surgery or for any procedure that may be fright-
examination of particular age-groups for ening or uncomfortable.
example, children or the elderly and screening
tests are examples of secondary prevention. Sedatives
Drugs and other measures which have a calm-
Secondary Sexual ing effect, reducing tension and anxiety. They
Characteristics include ANXIOLYTICS and HYPNOTICS (usually
The physical characteristics that develop during given in smaller doses than is needed to induce
PUBERTY as the body matures sexually. Girls sleep).
breasts and genitals increase in size, and, like
boys, they grow pubic hair. Boys also grow Sedimentation Rate
facial hair, their voice breaks and their genitals See ESR.
grow to adult size.
Seizure
Secretin Also called a FIT, this is a sudden burst of
A hormone (see HORMONES) secreted by the uncontrolled electrical activity in the BRAIN. A
mucous membrane of the duodenum, the first seizure may be generalised or partial: in the
part of the small INTESTINE, when food comes former, abnormal electrical activity may affect
in contact with it. On being carried by the the whole brain, resulting in unconsciousness
blood to the PANCREAS, it stimulates the secre- and characteristic of EPILEPSY; in partial seiz-
tion of pancreatic juice. ures, abnormal electrical activity occurs in one
part of the brain. HALLUCINATIONS may occur
Secretion and localised symptoms include muscular
The term applied to the material formed by a twitching or a tingling sensation in a small area
GLAND as the result of its activity. For example, of the face, arm, leg or trunk. Different neuro-
saliva is the secretion of the salivary glands; gas- logical or medical disorders may cause seizures:
tric juice that of the glands in the stomach wall; for example, STROKE, brain tumour, head
bile that of the liver. Some secretions consist injury, infection or metabolic disturbance (see
apparently of waste material which is of no fur- METABOLISM; METABOLIC DISORDERS). People
ther use in the chemistry of the body. These dependent on alcohol may suffer seizures if they
secretions are often spoken of as excretions: for stop drinking. Treatment is of the underlying
example, the URINE and the sweat see PERSPIR- condition coupled with antiepileptic drgus such
ATION. (For further details, see ENDOCRINE as CARBAMAZEPINE, lamotrigine, SODIUM
GLANDS, and also under the headings of the VALPROATE or PHENYTOIN SODIUM.
various organs.)
Selective Serotonin-Reuptake
Section Inhibitors (SSRIs)
(1) A thin slice of a tissue specimen taken for These ANTIDEPRESSANT DRUGS have few
examination under a microscope. antimuscarinic effects (see ANTIMUSCARINE),
S (2) The act of cutting in surgery; for example, but do have adverse effects of their own pre-
an abdominal section is done to explore the dominantly gastrointestinal. They are, however,
abdomen. much safer in overdose than the tricyclic anti-
(3) The issuing of an order under the United depressants, which is a major advantage in
Kingdoms Mental Health Act to admit some- patients who are potentially suicidal. Examples
one compulsorily to a psychiatric hospital. are citalopram, used to treat panic disorders, as
well as depressive illness; FLUOXETINE; and
Secundines PAROXETINE. (See also MENTAL ILLNESS.)
Another name for the afterbirth, consisting of
the PLACENTA and membranes expelled in the Selegiline
final stage of labour (see PREGNANCY AND A monoamine-oxidase-B-inhibiting drug used
LABOUR). in conjunction with LEVODOPA to treat severe
PARKINSONISM. Early treatment with selegiline
Sedation may delay the need to give the patient levo-
The production of a calm and peaceful state of dopa, but at present there is no firm evidence
mind, especially by the use of SEDATIVES. The that it slows down the progression of the
aim is to reduce abnormal anxiety and bring disease.
 Sensation 637

Selenium Sulphide men than does TERATOMA. The treatment is

This is used as a shampoo in the treatment of surgical removal. (See also TESTICLE, DISEASES
dandruff and seborrhoeic DERMATITIS of the OF.)
scalp. In view of its potential toxicity it should
only be used under medical supervision. It must Senile Dementia
never be applied to inflamed areas of the scalp, DEMENTIA was traditionally divided into prese-
and it must not be allowed to get into the eyes nile and senile types; this is increasingly recog-
as it may cause conjunctivitis or keratitis. It is nised as an arbitrary division of a condition in
also used in the treatment of tinea versicolor (see which there is a general and often slow decline
RINGWORM). in mental capabilities. Around 10 per cent of
people over 65 years of age and 20 per cent over
Self-Poisoning 75 are affected by dementing illness, but people
See POISONS. under 65 may also be affected. Treatable causes
such as brain tumour, head injury, ENCEPHA-
Sella Turcica LITIS and alcoholism are commoner in younger
The deep hollow on the upper surface of the people. Other causes such as cerebrovascular
sphenoid bone in which the PITUITARY GLAND disease which is a major factor, especially
is enclosed. among older people or ALZHEIMERS DISEASE
are not readily treatable, although ANTIHYPER-
Semen TENSIVE DRUGS for the former disorder may
Fluid produced by the male on ejaculation from help, and symptomatic treatment for both is
the penis at sexual orgasm. Each ejaculate con- possible.
tains up to 500 million spermatozoa (male Individuals with dementia suffer a gradual
germ cells) suspended in a fluid that is secreted deterioration of memory and of the ability to
by the PROSTATE GLAND, seminal vesicles (see grasp what is happening around them. They
TESTICLE), and Cowpers glands a pair of often cover up their early failings and the condi-
small glands (also called the bulbo-urethral tion may first become apparent as a result of
glands) that open into the URETHRA at the base emotional outbursts or uncharacteristic
of the penis. Semen, or seminal fluid, contains a behaviour in public. Eventually personal habits
form of sugar (fructose) essential for the motil- and speech deteriorate and they become thor-
ity of sperm. The hormone TESTOSTERONE is a oughly confused and difficult to look after.
key element in the production of sperm and of Treatment is primarily a matter of ameliorating
seminal fluid. the symptoms, coupled with a sympathetic
handling of the sufferer and the relatives.
Semilunar Cartilages Admission to hospital or nursing home may be
Two crescentic layers of fibro-cartilage on the necessary if relatives are unable to look after the
outer and inner edges of the knee-joint, which patient at home. (See also MEDICINE OF THE
AGEING.)
form hollows on the upper surface of the tibia
in which the condyles at the lower end of the
femur rest. The inner cartilage is especially Senility
liable to be displaced by a sudden and violent See AGEING.
S
movement at the KNEE.
Senna
Seminal Vesicle The leaves of various species of Cassia senna. It
One of the small paired sacs lying on either side is one of the most active of the simple laxative
of the male URETHRA, which collect and store drugs (see LAXATIVES). Senna is excreted in the
spermatozoa. (See TESTICLE.) urine, giving it a dark red or yellow colour. In
the case of nursing mothers, some of the drug
Seminiferous Tubules is excreted in the milk and may affect the
The long tortuous tubules that form much of infant. A standardised preparation of senna,
the testis (see TESTICLE) and carry the SEMEN to Senokot, is widely used for the management
the URETHRA. of constipation in children and old people. A
side-effect of senna is HYPOKALAEMIA; like
Seminoma other laxatives, it should not be used too often.
A malignant tumour of the testis (see TESTICLE)
that appears as an often painless swelling. This Sensation
tumour usually occurs in an older age-group of See PAIN; TOUCH.
 638 Sensitisation

Sensitisation heart failure may develop. A small septal defect

See ALLERGY; ANAPHYLAXIS. may not need treatment but a large one will
need to be repaired surgically.
Sensitivity
The extent to which a SCREENING TEST detects Septicaemia
the proportion of true cases of the disease being A serious condition caused by the presence of
screened. micro-organisms in the bloodstream. A very
high temperature may be the only sign, but
Sensory there is often associated shivering (rigor), pro-
Description applied to the part of the nervous fuse sweating and pains in the joints and
system dedicated to bringing information on muscles. If the condition is not brought to a
sensations affecting the body to the brain. The halt by the early use of high-dose antibiotics,
opposite of sensory nerves is motor nerves; preferably given intravenously, SEPTIC SHOCK
these carry instructions for action to the volun- may supervene and the patients life be put at
tary muscles in the body. risk. Any infected area of the body may progress
to septicaemia if untreated.
Sensory Cortex
See BRAIN. Septic Arthritis
Infection in a joint which becomes warm, swol-
Sensory Deprivation len and sore, with restricted movement. The
A substantial reduction in the volume of SENS- infectious agent may enter the joint as a result
ORY information impinging on the body for of a penetrating wound or via the bloodstream.
instance, sitting in a dark, silent room. Pro- The condition is treated by ARTHROTOMY or
longed deprivation is potentially harmful as the ARTHROSCOPY, joint irrigation and ANTI-
body needs constant stimulation in order to BIOTICS. Unless treated, the articular CARTIL-
function normally. The main input organs are AGE of the joint is destroyed, resulting in a
the eyes, ears, skin and nose. The absence of painful, deformed and sometimes immobile
sensations disorients a person and results in joint. (See ARTHRITIS.)
neurological dysfunction. Some interrogation
techniques involve sensory deprivation to Septic Shock
soften up the individual being questioned. A dangerous disorder characterised by a severe
fall in blood pressure and damage to the body
Sepsis tissues as a result of SEPTICAEMIA. The toxins
Poisoning by the products of the growth of from the septicaemia cause widespread damage
micro-organisms in the body, the general to tissue, provoke clotting in small blood ves-
symptoms which accompany it are those of sels, and seriously disturb the circulation. The
INFLAMMATION. Sepsis is prevented by the kidneys, lungs and heart are particularly
various procedures mentioned under ASEPSIS, affected. The condition occurs most commonly
and is treated locally with ANTISEPTICS and in people who already have a chronic disease
systemically with ANTIBIOTICS. such as cancer, CIRRHOSIS of the liver or DIA-
BETES MELLITUS. Septic shock may also develop
S Septal Defect in patients with immunodeficiency illnesses
A congenital abnormality of the HEART affect- such as AIDS (see AIDS/HIV). The symptoms are
ing about 260 babies in every 100,000, in those of septicaemia, coupled with those of
which there is a hole in the septum the divid- SHOCK: cold, cyanotic limbs; fast, thready
ing wall between the left and right sides of the pulse; and a lowered blood pressure. Septic
heart. The effects of the defect depend upon its shock requires urgent treatment with ANTI-
size and position. A defect in the wall between BIOTICS, intravenous fluids and oxygen, and
the atria (upper chambers of the heart) is called may require the use of drugs to maintain blood
an atrial septal defect, and that between the pressure and cardiac function, artificial ventila-
ventricles, a ventricular septal defect the most tion and/or renal DIALYSIS.
common form (25 per cent of all defects). Both
defects allow blood to circulate from the left Septum
side of the heart, where pressures are highest, to A dividing wall within a structure in the body.
the right. This abnormal flow of blood is Examples are the divisions between the cham-
described as a shunt and the result is that too bers of the heart, and the layer of bone and
much blood flows into the lungs. PULMONARY cartilage that separates the two nostrils of the
HYPERTENSION occurs and, if the shunt is large, nose.
 Serum Sickness 639

Sequelae Serous Membranes

The term applied to symptoms or effects which These are smooth, transparent membranes that
are liable to follow certain diseases. For line certain large cavities of the body. The chief
example, BRONCHITIS and other chest com- serous membranes are the PERITONEUM, lining
plaints may be sequelae of MEASLES; heart dis- the cavity of the abdomen; the pleurae (see
ease is often a sequelae of RHEUMATIC FEVER; PLEURA), one of which lines each side of the
PARALYSIS may follow DIPHTHERIA. chest, surrounding the corresponding lung; the
PERICARDIUM, in which the heart lies; and
Sequestrum the tunica vaginalis on each side, enclosing a
A fragment of dead bone cast off from the living testicle. The name of these membranes is
bone in the process of NECROSIS. (See also BONE, derived from the fact that the surface is mois-
DISORDERS OF.) A sequestrum often remains in tened by thin fluid derived from the serum of
contact with, and partly enveloped by, newly blood or LYMPH. Every serous membrane con-
formed bone, so that a SINUS is produced; a sists of a visceral portion, which closely
constant discharge goes on until the dead bone envelops the organs concerned, and a parietal
is removed. portion, which adheres to the wall of the cavity.
These two portions are continuous with one
Seroconversion another so as to form a closed sac, and the
The production of specific ANTIBODIES to anti- opposing surfaces are close together, separated
gens (see ANTIGEN) present in the body. This only by a little fluid. This arrangement enables
may happen as a result of infection by a virus, the organs in question to move freely within the
or IMMUNISATION with a VACCINE. Thus, if cavities containing them. For further details, see
blood has been tested before the event there under PERITONEUM.
may be little or no evidence of antibody to the
condition in question; but when a sample is Serpiginous
taken 12 weeks later there may be a high level A term describing a creeping or extending skin
of antibody confirming that recent infection lesion such as an ULCER.
has taken place. Sometimes this is the only way
to prove that a particular infection has occurred Serum
or that a vaccination has taken. The fluid which separates from blood, LYMPH,
and other body fluids when clotting occurs (see
Serotonin COAGULATION; HAEMORRHAGE). PLASMA is
Also known as 5-hydroxytryptamine, this is a the fluid of the blood, including FIBRIN, which
substance widely distributed in the body tis- carries the circulating blood cells and
sue, but especially in the PLATELETS in the PLATELETS.
blood, the lining of the gastrointestinal tract, Serum is a clear, yellowish fluid containing
and the BRAIN. Serotonin is believed to have a around 7 per cent proteins and globulins, small
similar function to that of HISTAMINE in quantities of salts, fat, sugar, urea, and uric acid,
INFLAMMATION. In the gut it inhibits gastric and even smaller quantities of immuno-
secretion and stimulates smooth (involuntary) globulins, essential in the prevention of disease
muscle in the walls of the INTESTINE. Sero- (see IMMUNITY; IMMUNOLOGY). The serum
tonin participates in the transmission of nerve given in the commonly used vaccines is gener- S
impulses and may have a function in control- ally derived from horses blood, after they have
ling mood and states of consciousness. (See also been subjected to a long course of treatment.
SELECTIVE SEROTONIN-REUPTAKE INHIBITORS
(SSRIS).) Serum Sickness
A hypersensitivity reaction due to circulating
Serotype antigen-antibody complexes (see ANTIGEN;
A classification of a substance according to its ANTIBODIES), so-called because it was a not
serological activity. This is done in the context uncommon reaction to the administration of
of the antigens (see ANTIGEN) that it contains, or foreign SERUM which used to be given as a form
the ANTIBODIES it may provoke. Micro- of passive IMMUNITY before the days of anti-
organisms of the same species may be classified biotics. By definition, it is a manifestation of
according to the different antigens that they sensitivity to serum but the same clinical and
produce. pathological picture can occur 13 weeks after
the administration of drugs such as PENICILLIN
Serous and STREPTOMYCIN. It is characterised by fever,
Relating to, containing or resembling SERUM. ARTHRALGIA and LYMPHADENOPATHY and is
 640 Serum Therapy

usually self-limiting as it resolves when the sup- the offspring will be male. It is the sex chromo-
ply of antigen is used up. somes which determine the sex of an individual.
Sometimes during cell division chromo-
Serum Therapy somes may be lost or duplicated, or abnormal-
See IMMUNOLOGY. ities in the structure of individual chromosomes
may occur. The surprising fact is the
Sesamoid Bones infrequency of such errors. About one in 200
Rounded nodules of bone usually embedded in live-born babies has an abnormality of devel-
tendon. They are usually a few millimetres in opment caused by a chromosome, and two-
diameter, but some are larger, such as the thirds of these involve the sex chromosomes.
PATELLA, or knee-cap. There is little doubt that the frequency of these
abnormalities in the early embryo is much
Sessile higher, but because of the serious nature of the
A growth or tumour that has no stalk. defect, early spontaneous ABORTION occurs.
Chromosome studies on such early abortions
Severe Acute Respiratory show that half have chromosome abnormalities,
Syndrome (SARS) with errors of autosomes being three times as
See SARS. common as sex chromosome anomalies. Two of
the most common abnormalities in such fetuses
Sevoflurane are triploidy with 69 chromosomes and trisomy
A quick-acting volatile liquid anaesthetic (see of chromosome 16. These two anomalies
ANAESTHESIA). Emergence and recovery from almost always cause spontaneous abortion.
anaesthetic are rapid, and early post-operative Abnormalities of chromosome structure may
measures to control pain are advised. arise because of:

Sex Change Deletion Where a segment of a chromosome

A major surgical operation, usually coupled is lost.
with the appropriate hormone treatment (see
HORMONES), to change a persons anatomical Inversion Where a segment of a chromosome
sex. The operation is done on transsexual indi- becomes detached and re-attached the other
viduals or in those whose sexual organs are nei- way around. GENES will then appear in the
ther totally female nor male. Male-to-female sex wrong order and thus will not correspond with
change is the more common. Such operations their opposite numbers on homologous
should not be performed without rigorous chromosomes.
physical and mental assessment of the indi-
vidual, and should be accompanied by extensive Duplication Where a segment of a chromo-
counselling. Some subjects make a satisfactory some is included twice over. One chromosome
adjustment to the change of anatomical sex, will have too little nuclear material and one too
while others may suffer serious psychological much. The individual inheriting too little may
problems. Hormone therapy may need to be be non-viable and the one with too much may
continued for life. be abnormal.
S
Sex Chromosomes Translocation Where chromosomes of dif-
In humans there are 23 pairs of CHROMO- ferent pairs exchange segments.
SOMES. Male and female differ in respect of one
pair. In the nucleus of female cells, the two Errors in division of centromere Some-
members of the pair are identical and are called times the centromere divides transversely
X chromosomes. In the male nucleus there is instead of longitudinally. If the centromere is
one X chromosome paired with a dissimilar, not central, one of the daughter chromosomes
differently sized chromosome called the Y will arise from the two short arms of the parent
chromosome. In the sex cells, after MEIOSIS, all chromosome and the other from the two long
cells in the female contain a single X chromo- arms. These abnormal daughter chromosomes
some. In the male, half will contain an X are called isochromosomes.
chromosome and half a Y chromosome. If a These changes have important bearings on
sperm with an X chromosome fertilises an heredity, as the effect of a gene depends not
ovum (which, as stated, must have an X only upon its nature but also upon its position
chromosome) the offspring will be female; if a on the chromosome with reference to other
sperm with a Y chromosome fertilises the ovum genes. Genes do not act in isolation but against
 Sex Education 641

the background of other genes. Each gene nor- (XY) or none at all. (See also CHROMOSOMES;
mally has its own position on the chromosome, GENES.)
and this corresponds precisely with the positon
of its allele on the homologous chromosome of Sex Education
the pair. Each member of a pair of chromo- Information given to children and young adults
somes will normally carry precisely the same about sexual relationships. Evidence suggests
number of genes in exactly the same order. that young people want more information
Characteristic clinical syndromes, due to about the emotional aspects of sexual relation-
abnormalities of chromosome structure, are less ships, and about homosexuality and AIDS/HIV.
constant than those due to loss or gain of a There is growing concern about sexual risk-
complete chromosome. This is because the taking behaviour among adolescents, many of
degree of deletion, inversion and duplication is whom feel that sex education was provided too
inconstant. However, translocation between late for them. Although most parents or guard-
chromosomes 15 and 21 of the parent is associ- ians provide some guidance by the age of 16,
ated with a familial form of mongolism (see friends, magazines, television and films are a
DOWNS (DOWN) SYNDROME) in the offspring, more significant source of information. Schools
and deletion of part of an X chromosome may have been targeted as a place to address and
result in TURNERS SYNDROME. possibly limit risky behaviour because they are
geared towards increasing knowledge and
Non-disjunction Whilst alterations in the improving skills, and have a captive audience of
structure of chromosomes arise as a result of young adults. There are concerns that the con-
deletion or translocation, alterations in the ditions in schools may not be ideal: class time is
number of chromosomes usually arise as a result limited; teachers are often not trained in hand-
of non-disjunction occurring during matur- ling sensitive subjects; and considerable contro-
ation of the parental gametes (germ cells). The versy surrounds teaching about subjects such as
two chromosomes of each pair (homologous homosexuality.
chromosomes) may fail to come together at the Sex education in schools is regarded as an
beginning of meiosis and continue to lie free. If effective way of reducing teenaged pregnancy,
one chromosome then passes to each pole of the especially when linked with contraceptive ser-
spindle, normal gametes may result; but if both vices. Several studies have shown that it does
chromosomes pass to one pole and neither to not cause an increase in sexual activity and may
the other, two kinds of abnormal gametes will even delay the onset of sexual relationships and
be produced. One kind of gamete will contain lessen the number of partners. Programmes
both chromosomes of the pair, and the other taught by youth agencies may be even more
gamete will contain neither. Whilst this results effective than those taught in the classroom
in serious disease when the autosomes are possibly because teaching takes place in small
involved, the loss or gain of sex chromosomes groups of volunteer participants, and the pro-
seems to be well tolerated. The loss of an auto- grammes are tailored to their target popula-
some is incompatible with life and the mal- tions. Despite improvements in sex education,
formation produced by a gain of an autosome is the United Kingdom has the highest incidence
proportional to the size of the extra chromo- of teenaged pregnancies in the European
some carried. Community. S
Only a few instances of a gain of an auto- Sex education, including information about
some are known. An additional chromosome AIDS/HIV and other sexually transmitted
21 (one of the smallest autosomes) results in infections (STIs), is compulsory in all state-
mongolism, and trisomy of chromosome 13 maintained secondary schools in England and
and 18 is associated with severe mental, skeletal Wales. The National Curriculum includes only
and congenital cardiac defects. Diseases result- biological aspects of AIDS/HIV, STIs and
ing from a gain of a sex chromosome are not as human sexual behaviour.
severe. A normal ovum contains 22 autosomes All maintained schools must have a written
and an X sex chromosome. A normal sperm statement of their policy, which is available to
contains 22 autosomes and either an X or a Y parents. The local education authority, govern-
sex chromosome. Thus, as a result of non- ing body and headteacher should ensure that
disjunction of the X chromosome at the first sex education encourages pupils to have due
meiotic division during the formation of female regard to moral considerations and the value of
gametes, the ovum may contain two X chromo- family life. Sex-education policies and practices
somes or none at all, whilst in the male the are monitored by the Office for Standards in
sperm may contain both X and Y chromosomes Education (OFSTED) and the Office of HM
 642 Sex Hormones

Chief Inspector of Schools (OHMCI) as part of shoes or clothes (fetishism). Different cultures
school inspections. have different values, and treatment is probably
not required unless the deviation is antisocial
Sex Hormones or harmful to the participant(s). Aversion
These HORMONES control the development of therapy, or the conditioning of a persons
primary and secondary sexual characteristics. behaviour, may help if treatment is considered
They also regulate sex-related functions for necessary.
example, menstruation and the production of
sperm and eggs. The three main types of sex Sexual Dysfunction
hormone are androgens, or male sex hormones Inadequate sexual response may be due to a lack
(see ANDROGEN); OESTROGENS, or female sex of sexual desire (LIBIDO) or to an inadequate
hormones; and progesterones, which are performance; or it may be that there is a lack of
involved in pregnancy (see PROGESTERONE). satisfaction or ORGASM. Lack of sexual desire
may be due to any generalised illness or endo-
Sex-Linked Inheritance crine disorder, or to the taking of drugs that
The way in which a characteristic or an illness antagonise endocrine function (see ENDOCRINE
determined by the SEX CHROMOSOMES in an GLANDS). Disorders of performance in men can
individuals cells is passed on to the succeeding occur during arousal, penetration and EJACU-
generation. Men have one X and one Y sex LATION. In the female, DYSPAREUNIA and
chromosome and women have two X chromo- VAGINISMUS are the main disorders of per-
somes. Disorders that result from an abnormal formance. DIABETES MELLITUS can cause a
number of sex chromosomes include KLINEFEL- neuropathy which results in loss of erection.
TERS SYNDROME, which affects only men, and IMPOTENCE can follow nerve damage from
TURNERS SYNDROME, which affects mainly operations on the PROSTATE GLAND and lower
women. Recessive GENES on the X chromosome bowel, and can be the result of neurological dis-
cause most other sex-linked characteristics; in eases affecting the autonomic system (see NER-
women these may well be masked because one VOUS SYSTEM). Disorders of satisfaction
of their two X chromosomes carries a normal include, in men, impotence, emission without
(dominant) gene. In men, who have just one X forceful ejaculation and pleasureless ejaculation.
chromosome, no such masking occurs so In women such disorders range from the
more men than women are affected by X-linked absence of the congestive genital response to
characteristics or diseases. (See also HEREDITY.) absence of orgasm. Erectile dysfunction in men
can sometimes be treated with SILDENAFIL CIT-
Sex Therapy
RATE (Viagra ), a drug that recent research
The counselling and treatment of individuals suggests may also be helpful to women with
with psychosexual dysfunction (see SEXUAL DYS- reduced libido and/or inability to achieve
FUNCTION). Around half of couples experience orgasm.
some type of sexual problem during their rela- Sexual dysfunction may be due to physical or
tionships, and for most of them the difficulties psychiatric disease, or it may be the result of the
are psychological. Sexual therapy is usually administration of drugs. The main group of
given to both partners, but sometimes indi- drugs likely to cause sexual problems are the
S vidual counselling is necessary. Couples may ANTICONVULSANTS, the ANTIHYPERTENSIVE
sometimes find that group therapy is helpful. DRUGS, and drugs such as metoclopramide that
Therapy has proved effective especially for induce HYPERPROLACTINAEMIA. The benzo-
women with VAGINISMUS (spasm of vaginal diazepine TRANQUILLISERS can reduce libido
muscles), men with PREMATURE EJACULATION and cause failure of erection. Tricyclic ANTI-
or IMPOTENCE, and men and women who fail DEPRESSANT DRUGS may cause failure of erec-
to achieve ORGASM. tion and clomipramine may delay or abolish
ejaculation by blockade of alpha-adrenergic
Sexual Abuse receptors. The MONOAMINE OXIDASE INHIBI-
See CHILD ABUSE. TORS (MAOIS) often inhibit ejaculation. The
PHENOTHIAZINES reduce sexual desire and
Sexual Deviation arousal and may cause difficulty in maintaining
Any type of pleasurable sexual practice which an erection. The antihypertensive drug, meth-
society regards as abnormal. Deviation may be yldopa, causes impotence in over 20 per cent of
related to the activity, such as EXHIBITIONISM patients on large doses. The beta-adrenoceptor-
or sadomasochistic sex (see SADISM; MASO- blockers and the DIURETICS can also cause
CHISM); or to the sexual object, for example, impotence. The main psychiatric causes of
 Shellfish Poisoning 643

sexual dysfunction include stress, depression regular use of condoms. In the United King-
and guilt. dom the rates per million of the male popula-
tion infected by syphilis rose from 8.8 in 1991
Sexually Transmitted Diseases to 9.7 in 1999; in females the figures were 4.0
(STDs) to 4.5, respectively. For gonorrhoea, the figures
Sexually transmitted diseases traditionally for men were 399.4 in 1991 and 385 in 1999,
called venereal diseases are infections trans- with women also showing a reduction, from
mitted by sexual intercourse (heterosexual and 216.5 to 171.3. In 1991, 552.6 per million of
homosexual). In the United Kingdom they are men had chlamydia, a figure which rose to
treated in genito-urinary medicine (GUM) 829.5 in 1999; for women in the same period
clinics. The incidences of these diseases are the incidence also rose, from 622.5 to 1,077.1
more common among people who have several per million. For genital herpes simplex virus,
sexual partners, as STDs are very infectious; the infection rate for men fell from 236.6 per
some of the major STDs, particularly AIDS/HIV, million to 227.7, whereas the figures for
are also transmitted by blood and so can result women showed a rise, 258.5 to 357. The inci-
from needle-sharing by drug addicts, or by dence of AIDS/HIV is given under the relevant
TRANSFUSION. The traditional STDs SYPH- entry. (These figures are based on information
ILIS, GONORRHOEA and CHANCROID now in United Kingdom Health Statistics, 2001 edi-
comprise only 10 per cent of all such diseases tion, UKHSI, published by the Office of
treated in STD clinics: these clinics also treat National Statistics.)
patients with CHLAMYDIA, TRICHOMONIASIS,
HERPES GENITALIS, MOLLUSCUM CONTAGIO- Shaken Impact Syndrome
SUM and genital WARTS. SCABIES and pubic lice A type of non-accidental head-injury to
(see PEDICULOSIS Pediculus pubis) can also be infants. A study published in 2000 (Lancet, 4
transmitted by sexual intercourse, and HEPA- November) suggests that almost 25 out of
TITIS B is also recognised as an STD. 100,000 children under a year old sustain
The incidence of STDs rose sharply during brain damage from shaken impact syndrome,
World War II but the advent of PENICILLIN and even if they do not strike any hard surface.
subsequent antibiotics meant that syphilis and So, of around 685,000 babies in this age-
gonorrhoea could be treated effectively. The group in Britain, as many as 170 a year may
arrival of oral contraception and more tolerant suffer injury from violent shaking. The
public attitudes to sexual activities resulted in median age for admission to hospital for
an increase in the incidence of sexually trans- the condition in Scotland was 2.2 months in
mitted infections. The diagnosis of NON- the 18 months from July 1998. A Swedish
SPECIFIC URETHRITIS (NSU), once given to many report has concluded that children at risk from
patients whose symptoms were not due to the CHILD ABUSE can be identified and the inci-
traditional recognised infections, was in the dence reduced by legislation banning corporal
1970s realised to be wrong, as the condition punishment. (See also NON-ACCIDENTAL INJURY
was proved to be the result of infection by (NAI).)
chlamydia.
Most STDs are treatable, but herpes is an Shellfish Poisoning
infection that could become chronic, while In the United Kingdom this occurs in two main S
hepatitis B and, of course, AIDS/HIV are forms. Shellfish may be the cause of typhoid
potentially fatal although treatment of HIV is fever (see ENTERIC FEVER) as a result of their
now proving more effective. As well as the contamination by sewage containing the causa-
treatment and subsequent monitoring of tive organism. They may also be responsible for
patients with STDs, one of the important func- what is known as paralytic shellfish poisoning.
tions of clinics has been the tracing, treatment This is caused by a toxin, or poison, known as
and follow-up of sexual contacts of infected saxotoxin, which is present in certain planktons
individuals, a procedure that is conducted which, under unusual conditions, multiply rap-
confidentially. idly, giving rise to what are known as red tides.
Apart from AIDS/HIV, the incidence of In these circumstances the toxin accumulates in
STDs fell during the 1980s; however in some mussels, cockles and scallops which feed by fil-
countries the agents causing syphilis and gonor- tering plankton. The manifestations of such
rhoea began to develop resistance to antibiotics, poisoning are loss of feeling in the hands, tingl-
which showed the continued importance of ing of the tongue, weakness of the arms and
practising safe sex in particular by restricting legs, and difficulty in breathing. There is also
the number of sexual partners and ensuring the growing evidence that some shellfish poisoning
 644 Sheltered Housing

may be due to a virus infection. (See also FOOD prevents the maintenance of a normal electro-
POISONING.) lyte and acid-base balance.

Sheltered Housing Treatment If the shock is a result of haemor-

Accommodation that has been adapted to cater rhage or diarrhoea or vomiting, replacement of
for the special requirements of those elderly blood, lost fluid and electrolytes is of prime
people who can largely look after themselves importance. If it is due to septicaemia, treat-
but benefit from some discreet supervision. The ment of the infection is of paramount import-
accommodation is usually a small flat, and a ance, and in addition, intravenous fluids and
warden will supervise a group of flats. Meals vasopressor drugs will be required. Cardiogenic
and other services may be provided, and the shock is treated by attention to the underlying
payment system varies depending on whether cause. Full intensive care is likely to be required,
the accommodation is privately owned or run and artificial ventilation and DIALYSIS may both
by a local social-services department. be needed.

Shigella Shock Lung

The name given to a group of rod-shaped, See ACUTE RESPIRATORY DISTRESS SYNDROME
gram-negative bacteria (see GRAMS STAIN) that (ARDS).
are the cause of bacillary DYSENTERY.
Shock Therapy
Shingles See ELECTROCONVULSIVE THERAPY (ECT).
See HERPES ZOSTER.
Short-Sight
Shin Splints A condition in which objects near at hand are
See MEDIAL TIBIAL SYNDROME. seen clearly, while objects at a distance are
blurred. The condition is technically known as
Shock myopia. (See EYE, DISORDERS OF Errors of
A state of acute circulatory failure in which the refraction; VISION.)
hearts output of blood is inadequate to pro-
vide normal PERFUSION of the major organs. It Short Stature
is accompanied by a fall in arterial blood pres- See DWARFISM.
sure and is characterised by systemic arterial
hypotension (arterial blood pressure less than Shoulder
80 mm of mercury), sweating and signs of The joint formed by the upper end of the
VASOCONSTRICTION (for example, pallor, HUMERUS and the shoulder-blade or SCAPULA.
CYANOSIS, a cold clammy skin and a low- The acromion process of the scapula and the
volume pulse). These signs may be associated outer end of the collar-bone (see CLAVICLE)
with clinical evidence of poor tissue perfusion, form a protective bony arch above the joint,
for example to the brain and kidneys, leading and from this arch the wide and thick deltoid
to mental apathy, confusion or restlessness and muscle passes downwards, protecting the outer
OLIGURIA. surface of the joint and giving to the shoulder
S Shock may result from loss of blood or its rounded character. The joint itself is of the
plasma volume. This may occur as a result of ball-and-socket variety, the rounded head of the
haemorrhage or severe diarrhoea and vomiting. humerus being received into the hollow glenoid
It may also result from peripheral pooling of cavity of the scapula, which is further deepened
blood due to such causes as TOXAEMIA or ANA- by a rim of cartilage. One tendon of the biceps
PHYLAXIS. The toxaemia is commonly the result muscle passes through the joint, grooving the
of a SEPTICAEMIA in which leakage through humerus deeply, and being attached to the
capillaries reduces circulating blood volume. upper edge of the glenoid cavity. The joint is
Another form is called cardogenic shock, and is surrounded by a loose fibrous capsule, strength-
due to failure of the heart as a pump. It is most ened at certain places by ligamentous bands.
commonly seen as a result of myocardial infarc- The main strength of the joint comes from the
tion (see under HEART, DISEASES OF). powerful muscles that unite the upper arm with
If failure of adequate blood flow to vital the scapula, clavicle and ribs.
organs is prolonged, the effects can be disas-
trous. The ischaemic intestine permits the Shoulder-blade or scapula. A flat bone,
transfer of toxic bacterial products and proteins about as large as the flat hand and fingers,
across its wall into the blood; renal ISCHAEMIA placed on the upper and back part of the
 Sigmoidoscopy 645

Posterior view of musculoskeletal structure of left shoulder.

thorax. Many of the large muscles that move applied to the intense competition that some-
the arm are attached to it. It is not in contact times occurs between brothers and/or sisters.
with the ribs, and its only attachment to the The birth of a new baby in the family may
trunk of the body is through a joint between its prompt jealousy and rivalry that can persist
acromion process and the clavicle on the tip of throughout life.
the shoulder and by the powerful muscles
which suspend it from the backbone and ribs. Sickle-Cell Anaemia
With the arm hanging by the side, the scapula See under ANAEMIA.
extends from the second to the seventh rib, but,
as the arm is raised and lowered, it slides freely Sickness
over the back of the chest. On the rear surface See VOMITING; MOTION (TRAVEL) SICKNESS.
of the bone is a strong process, the spine of the
scapula. This arches upwards and forwards into Side-Effects
the acromion process. The latter forms the This refers to an effect of a drug which is not
bony prominence on the top of the shoulder, that which doctor and patient require. Some
where it unites in a joint with the outer end of side-effects are almost inevitable: for example,
the clavicle. drowsiness with older ANTIHISTAMINE DRUGS;
others are very rare, such as REYES SYNDROME
Shunt with ASPIRIN. Some can be predicted to occur if
Passage of blood through a channel that is not the dose is raised, while others may occur at the
its normal one. This may occur as a result of a lowest of doses due to the individual patients
congenital deformity (see SEPTAL DEFECT) or of susceptibility. In deciding whether to prescribe
surgery for example, a porto-caval shunt in or take a drug, a balance must always be struck
which the main portal vein is joined up to the between its benefits and risks. (See also MEDI-
inferior vena cava. CINES Safe use of medicines.) S
Sialagogues Siderosis
Substances which produce a copious flow of Chronic FIBROSIS of the LUNGS occurring in
SALIVA. iron-workers and due to the inhalation of fine
iron particles. The term is also applied to the
Sialorrhoea condition in which there is an excessive deposit
Also called ptyalism, this is the excessive pro- of iron in the tissues of the body.
duction of SALIVA. It occurs in various nervous
disorders, such as PARKINSONISM; poisoning by SIDS
MERCURY or mushrooms; or RABIES infection. See SUDDEN INFANT DEATH SYNDROME (SIDS).

Siamese Twins Sight

See CONJOINED TWINS; MULTIPLE BIRTHS. See VISION.

Sibling Sigmoidoscopy
A brother or sister. Sibling rivalry is the term Examination of the RECTUM and sigmoid
 646 Sildenafil Citrate

COLON (see also INTESTINE) with an endoscopic Silicone is also used to make implants for
viewing device called a sigmoidoscope (see also RECONSTRUCTIVE (PLASTIC) SURGERY. Silicone
ENDOSCOPE). The procedure is done to investi- oil in a silicone rubber bag is used in breast
gate rectal bleeding or persistent diarrhoea, with reconstruction after surgery for breast cancer,
the aim of detecting or excluding cancer of the and for enlargement of the breast. Although
rectum and COLITIS. Sigmoidoscopy, which usually an inert substance, it has been found to
nowadays is performed with a flexible instru- cause side-effects, including possible immuno-
ment, can usually be performed on an out- logical reactions following leakages, so that its
patient basis. use in breast surgery in particular has now been
restricted.
Sildenafil Citrate
An oral drug better known to the public as Silicosis
Viagra for treating erectile dysfunction of The most important industrial hazard in
the PENIS (see also ERECTION; SEXUAL DYSFUNC- those industries in which SILICA is
TION). Sildenafil citrate was originally encountered: in other words, the pottery
developed to treat ANGINA PECTORIS; during industry, the sandstone industry, sand-
clinical trials, patients reported that they were blasting, metal-grinding, the tin-mining
having more erections than before taking the industry, and anthracite coal-mines. It is a
drug. Clinical trials were then conducted on specific form of PNEUMOCONIOSIS caused by
4,000 men, and 70 per cent of them found the inhalation of free silica. Among pottery
sildenafil effective. The men, of an average age workers the condition has for long been
of 55 years, had experienced erectile problems known as potters asthma, whilst in the cut-
for around five years before taking part in the lery industry it was known as grinders rot.
trials. The medical conditions associated with For the production of silicosis, the particles of
their problems included high blood pressure, silica must measure 055 micrometres in
high concentrations of CHOLESTEROL, DIA- diameter, and they must be inhaled into the
BETES MELLITUS, surgery and psychological alveoli (air sacs) of the lungs, where they pro-
disorders. Among side-effects, headache was the duce FIBROSIS. This diminishes the efficiency
most common; others included facial flushing, of the lungs, resulting in slowly progressive
indigestion and a stuffy nose. The drug is a shortness of breath. The main danger of sili-
vasodilator so that blood flow to the penis is cosis, however, is that it is liable to be com-
enhanced. It works in response to sexual stimu- plicated by TUBERCULOSIS.
lation and has no properties as an aphrodisiac; The incidence of silicosis is steadily being
nor does it provoke sexual fantasies. Sildenafil reduced by various measures which diminish
must not be taken with drugs containing the risk of inhaling silica dust. These include
nitrates such as GLYCERYL TRINITRATE or iso- adequate ventilation to draw off the dust; the
sorbide trinitrate as the subject may suffer a suppression of dust by the use of water; the
sudden fall in blood pressure. Nitrates inhaled wearing of respirators where the risk is particu-
for recreational use (poppers) have a similar larly great and it is not possible to reduce the
effect. Recent research suggests that the drug amount of dust for example, in sand-blasting;
may help women with low LIBIDO or who have and periodic medical examination of work-
S difficulty in achieving ORGASM. people exposed to risk. Fewer than 100 new
cases a year are diagnosed now in the United
Silica Kingdom. (See also OCCUPATIONAL HEALTH,
A major constituent of the earths crust. Its MEDICINE AND DISEASES.)
main danger to health arises from free silica,
present mainly as quartz and flint and as an Simmonds Disease
important constituent of granite, sandstone and A rare condition in which wasting of the skin
slate. (See SILICOSIS.) and the bones, IMPOTENCE, and loss of hair
(ALOPECIA) occur as a result of destruction of
Silicones the PITUITARY GLAND.
Organic compounds of silicone, with a struc-
ture of alternate atoms of silicone and oxygen, Simvastatin
and organic groups such as methyl and One of the STATINS a group of LIPID-lowering
phenyl attached to the silicone atoms. As they drugs which are effective in combination with
produce a flexible and stable water-repellent a low CHOLESTEROL diet in reducing the
film on the skin, they are used as BARRIER incidence of heart attacks (see HEART, DISEASES
CREAMS. OF Coronary thrombosis).
 Skeleton 647

Singers Nodule Sinusoid

A small excrescence on the vocal cords (see A small blood vessel like an enlarged capillary
LARYNX) which causes hoarseness. This tends to (see CAPILLARIES) occurring, for example, in the
develop in people who abuse their voices for LIVER, which contains a large number of them.
example, singers, or people who shout The sinusoids in the liver are drained by the
excessively. hepatic veins.

Sinoatrial Node Sinus Tachycardia

This is the natural pacemaker of the HEART, A regular heart rate of 100 or more beats a min-
and comprises a collection of specialised muscle ute, caused by increased electrical activity in the
cells in the wall of the upper chamber (atrium) SINOATRIAL NODE (see also HEART). This level of
of the heart. The cells initiate electrical tachycardia is normal during and just after exer-
impulses at a rate of up to 100 a minute. These cise, and may also be caused by stress or anxiety.
impulses stimulate the muscles of the heart to If tachycardia persists when the person is rest-
contract. The rate is altered by the effects of ing, it may be due to underlying disease such as
certain hormones and various impulses from thyrotoxicosis (see under THYROID GLAND, DIS-
the nervous system. Damage or disease of the EASES OF) and investigation is advisable.
node affects the regular beating of the heart. (See
also CARDIAC PACEMAKER.) SI Units
The international system of measurement-units
Sinus used throughout the sciences. SI units, which
A term applied to narrow cavities of various derive from metres, kilograms, and seconds,
kinds, occurring naturally in the body, or comprise seven basic units and two supplemen-
resulting from disease. Thus it is applied to tary ones. Among the other base units are
the air-containing cavities which are found in ampere (electric current) and mole (amount of
the frontal, ethmoidal, sphenoidal and maxil- a substance at molecular level). Derived SI units
lary bones of the SKULL, and which com- include joule (energy), pascal (pressure), bec-
municate with the NOSE. The function of querel (activity), and newton (force). (See
these paranasal sinuses, as they are known, is APPENDIX 6: MEASUREMENTS IN MEDICINE.)
doubtful, but they do lighten the skull and
add resonance to the voice. They enlarge con- Sjogrens Syndrome
siderably around puberty and in this way are A disorder of CONNECTIVE TISSUE, with dry-
a factor in the alteration of the size and shape ness of the mouth (xerostomia) and dryness of
of the face. The term is also used in connec- the eye (kerato conjunctivitis sicca) occurring in
tion with the wide spaces through which the association with RHEUMATOID ARTHRITIS. It
blood circulates in the membranes (MENIN- occurs in approximately 10 per cent of patients
GES) of the BRAIN. Cavities which are pro- with the latter condition, but it can occur and
duced when an ABSCESS has burst, but remain frequently does so independently of rheuma-
unhealed, are also known as sinuses (see also toid disease. The lack of tears gives rise to symp-
FISTULA). toms of dryness and grittiness of the eyes; the
dry mouth can occasionally be so severe as to
Sinusitis cause a DYSPHAGIA. The disease is due to the S
Sinusitis is inflammation of the mucosal lining autoimmune destruction of the SALIVARY
of a SINUS. The term is usually applied to GLANDS and the lacrimal glands (see EYE
inflammation of the sinuses in the face. Most Lacrimal apparatus). The disorder is usually
cases occur as a result of infection spreading to associated with specific HLA antigen (see HLA
the sinuses from the NOSE along the passages SYSTEM). Treatment is unsatisfactory and is
that drain mucus secreted by the linings of the limited to oral and ocular hygiene as well as
sinuses to the nose. The bacterial infection usu- the provision of artificial tears in the form of
ally follows a viral infection of the upper cellulose eye drops.
respiratory tract. Treatment with ANTIBIOTICS
is usually effective but the condition tends to Skeletal Muscle
recur. If the episodes are severe, they can be Muscle under a persons voluntary control (see
disabling, with bad headaches. Surgery is some- MUSCLE; VOLUNTARY MUSCLE).
times necessary to drain the sinuses. Rarely,
sinusitis may lead to cerebral abscess or venous Skeleton
sinus thrombosis. The comprehensive term applied to the hard
structures that support or protect the softer
 648 Skin

tissues of the body. Many animals are possessed (pierced only by hairs and sweat-gland open-
of an exoskeleton, consisting of superficial ings) that are constantly rubbed off as small
plates of bone, horn, or the like; but in humans white scales; they are replaced by growing cells
the skeleton is entirely an endoskeleton, from below. The next, clear layer forms a type
covered everywhere by soft parts and consisting of membrane below which the granular stratum
mainly of bones, but in places also of cartilage. cells are changing from their origins as kerati-
The chief positions in which cartilage is found nocytes in the germinative zone, where fine
in place of bone are the larynx and the front of sensory nerves also terminate. The basal layer of
the chest. (For details of the skeleton, see BONE.) the germinative zone contains melanocytes
which produce the pigment MELANIN, the cause
Skin of skin tanning.
The membrane which envelops the outer sur-
face of the body, meeting at the bodys various Nail A modification of skin, being analagous
orifices, with the mucous membrane lining the to the horny layer, but its cells are harder and
internal cavities. more adherent. Under the horny nail is the nail
bed, comprising the well-vascularised corium
Structure (see above) and the germinative zone. Growth
CORIUM The foundation layer. It overlies the occurs at the nail root at a rate of around 05
subcutaneous fat and varies in thickness from mm a week a rate that increases in later years
053.0 mm. Many nerves run through the cor- of life.
ium: these have key roles in the sensations of Skin functions By its ability to control
touch, pain and temperature (see NEURON(E)). sweating and open or close dermal blood ves-
Blood vessels nourish the skin and are primarily sels, the skin plays a crucial role in maintaining
responsible for regulating the body tempera- a constant body temperature. Its toughness pro-
ture. Hairs are bedded in the corium, piercing tects the body from mechanical injury. The
the epidermis (see below) to cover the skin in epidermis is a two-way barrier: it prevents the
varying amounts in different parts of the body. entry of noxious chemicals and microbes, and
The sweat glands are also in the corium and prevents the loss of body contents, especially
their ducts lead to the surface. The fibrous tis- water, electrolytes and proteins. It restricts elec-
sue of the corium comprises interlocking white trical conductivity and to a limited extent pro-
fibrous elastic bundles. The corium contains tects against ultraviolet radiation.
many folds, especially over joints and on the The Langerhans cells in the epidermis are
palms of hands and soles of feet with the epi- the outposts of the immune system (see IMMUN-
dermis following the contours. These are per- ITY), just as the sensory nerves in the skin are
manent throughout life and provide unique the outposts of the nervous system. Skin has a
fingerprinting identification. social function in its ability to signal emotions
HAIR Each one has a root and shaft, and its such as fear or anger. Lastly it has a role in the
varying tone originates from pigment scattered synthesis of vitamin D.
throughout it. Bundles of smooth muscle
(arrectores pilorum) are attached to the root Skin, Diseases of
and on contraction cause the hair to stand They may be local to the SKIN, or a manifest-
S vertical. ation of systemic disorders inherited or
GLANDS These occur in great numbers in the acquired. Some major types are described
skin. SEBACEOUS GLANDS secrete a fatty sub- below.
stance and sweat glands a clear watery fluid (see Others appear under their appropriate
PERSPIRATION). The former are made up of a alphabetical headings: ACNE; ALBINISM; ALO-
bunch of small sacs producing fatty material PECIA; ALOPECIA AREATA; APHTHOUS ULCER;
that reaches the surface via the hair follicle. BASAL CELL CARCINOMA; BOILS (FURUN-
Around three million sweat or sudoriparous CULOSIS); BOWENS DISEASE; CALLOSITIES;
glands occur all over the body surface; sited CANDIDA; CHEILOSIS; CHEIRAPOMPHOLYX;
below the sebaceous glands they are uncon- DANDRUFF; DERMATOFIBROMA; DERMATOMY-
nected to the hairs. OSITIS; DERMATOPHYTES; DERMOGRAPHISM;
EPIDERMIS This forms the outer layer of skin ECTHYMA; ERYSIPELAS; ERYTHEMA;
and is the cellular layer covering the body sur- ERYTHRASMA; ERYTHRODERMA; ESCHAR;
face: it has no blood vessels and its thickness EXANTHEM; FUNGAL AND YEAST INFECTIONS;
varies from 1 mm on the palms and soles to 01 HAND, FOOT AND MOUTH DISEASE; HERPES
mm on the face. Its outer, impervious, horny GENITALIS; HERPES SIMPLEX; HERPES ZOSTER;
layer comprises several thicknesses of flat cells IMPETIGO; INTERTRIGO; KELOID; KERATOSIS;
 Skin, Diseases of 649

LARVA MIGRANS; LICHEN; LUPUS; MADURA important cause. BASAL CELL CARCINOMA is the
FOOT; MELANOMA; MILIARIA; MOLLUSCUM most common form; squamous cell carcinoma
CONTAGIOSUM; MOLE; MYCOSIS FUNGOIDES; is less common and presents as a growing, usu-
NAEVUS; ORF; PEDICULOSIS; PEMPHIGUS; ally painless nodule which may ulcerate. Squa-
PHOTOCHEMOTHERAPY; PHOTODERMATOSES; mous cancer may spread to regional lymph
PITYRIASIS; PORPHYRIAS; PRURITUS; PSORIASIS; glands and metastasise, unlike basal cell cancer.
RINGWORM; ROSACEA; SARCOIDOSIS; SCABIES; Occupational exposure to chemical carcinogens
SCLERODERMA; URTICARIA; VITILIGO; WARTS; may cause squamous carcinoma for example,
XANTHOMATA. cancer from pitch warts or the scrotal carcin-
oma of chimney sweeps exposed to coal dust in
Skin cancer Primary cancer is common and earlier centuries. Squamous carcinoma of the
chronic exposure to ultraviolet light is the most lip is associated with clay-pipe smoking.

Vertical section through the skin including hair and sweat glands.
 650 Skin-Grafting

Cancer may arise from the population of hypertension in the leg, consequent on valvular
melanocytes of the skin (see MELANOCYTE; incompetence in the deep leg veins owing to
MELANOMA). previous deep vein thrombosis (see VEINS, DIS-
Apart from these three most frequent forms EASES OF), is the usual cause.
of skin cancer, various forms of cancer can arise NEURODERMATITIS A pattern of well-defined
from cells of the dermis, of which LYMPHOMA is plaques of lichenified eczema particularly seen
the most important (see also MYCOSIS on the neck, ulnar forearms or sides of the
FUNGOIDES). calves in subjects under emotional stress.
Lastly, secondary deposits from internal IRRITANT CONTACT DERMATITIS Most often
cancer, particularly from the breast, may metas- seen in an industrial setting (occupational
tasise to the skin. dermatitis), it is due to damage by strong chem-
icals such as cutting oils, cement, detergents
Dermatitis and eczema These are and solvents. In almost all cases the hands are
broadly synonymous, and the terms are fre- most severely affected.
quently interchangeable. Eczema is a pattern of ALLERGIC CONTACT DERMATITIS, in contrast,
inflammation with many potential causes. can affect any part of the body depending on
Dermatitis is commonly used to suggest an the cause for example, the face (cosmetics),
eczema caused by external factors; it is a com- hands (plants, occupational allergens) or soles
mon pattern of inflammation of the skin char- (rubber boots). Particularly common allergens
acterised by redness and swelling, vesiculation include metals (nickel and chromate), rubber
(see VESICLE), and scaling with intense itching addititives, and adhesives (epoxy resins).
and often exudation (weeping). Fissuring,
thickening (lichenification see LICHEN) and Treatment Avoidance of irritants and contact
secondary bacterial infection may follow. allergens, liberal use of EMOLLIENTS, and top-
Dermatitis can affect any part of the body. It ical application of corticosteroid creams and
may be genetically detemined or due to other ointments (see CORTICOSTEROIDS) are central.
internal factors, such as venous HYPERTEN-
SION in a leg, or stress. Often it is external in Skin-Grafting
origin due to strong irritants or chemical An operation in which large breaches of SKIN
allergens. (See also ALLERGY; ALLERGEN.) surface due to wounding, burns or ulceration
ATOPIC DERMATITIS is genetic in origin and are closed by TRANSPLANTATION of skin from
usually begins in infancy. It may persist for other parts. There are three methods by which
years, and ASTHMA, allergic RHINITIS and con- this is done. Most frequently the epidermis only
junctivitis (see under EYE, DISORDERS OF) hay is transplanted, using a method introduced by
fever may be associated. Atopic children Reverdin and by Thiersch, and known by their
tend to have multiple allergies, especially to names. For this purpose, a broad strip of epi-
inhaled allergens such as house-dust mite, cat dermis is shaved off the thigh or upper arm,
and dog dander and pollens. Allergy to foods is after the part has been carefully sterilised, and is
less common but potentially more dangerous, transferred bodily to the raw or ulcerated sur-
especially if to nuts, when it can cause acute face, or is cut into smaller strips and laid upon
URTICARIA or even ANAPHYLAXIS. Atopic sub- it. A second method is for small pieces of the
S jects are particularly prone to persistent and skin in its whole thickness to be removed from
multiple verrucae (see WARTS) and mollusca the arm and thigh, or even from other people,
(see MOLLUSCUM CONTAGIOSUM) and to and then implanted and bound upon the raw
severe HERPES SIMPLEX infections. (See also surface. (This method has the disadvantage that
ATOPY.) the true skin must contract at the spot from
EXFOLIATE DERMATITIS (PITYRIASIS RUBRA) which the graft is taken, leaving an unsightly
Generalised exfoliation and scaling of the skin, scar.) When very large areas require to be
commonly with ERYTHEMA. Drugs may cause covered, a third method is commonly used. A
it, or the disorder may be linked with other skin large flap of skin, amply sufficient to cover the
diseases such as benign dermatoses and lupus gap, is raised from a neighbouring or distant
erythematosus (see under LUPUS). part of the body, in such a way that it remains
SUMMER POMPHOLYX is an acute vesicular attached along one margin, so that blood vessels
eczema of the palms and soles recurring every can still enter and nourish it. It is then turned
summer. Inhaled allergens are a frequent cause. so as to cover the gap; or, if it be situated on a
VENOUS (STASIS) DERMATITIS begins on a lower distant part, the two parts are brought together
calf, often in association with PURPURA, swell- and fixed in this position until the flap grows
ing and sometimes ulceration. Chronic venous firmly to its new bed. The old connection of the
 Sleep 651

flap is then severed, leaving it growing in its Sleep

new place. Sleep is a state which alternates with wakeful-
Researchers are having success in growing ness, and in which awareness and responsive-
human skin in the laboratory for grafting on to ness to the environment are reduced. It is not,
people who have been badly burned and have however, uniform and can be divided into two
insufficient intact skin surface to provide an main states differentiated according to electrical
autologous graft (one provided by the recipient recordings of brain activity (EEG), of the
of the graft). Other techniques being researched muscles (EMG), and of the eye movements
are the use of specially treated shark skin and (EOG).
the production of artificial skin.
Non-rapid-eye-movement (NREM)
Skull sleep This is subdivided into four stages, of
This is the collection of 22 flat and irregularly which stage 1 is the lightest and stage 4 the
shaped bones which protect the brain and form deepest. The activity of the cerebral cortex (see
the face (see BONE). BRAIN) is diminished and the bodys functions
are mainly regulated by brain-stem activity. The
Arrangement of the bones In child- metabolic rate is reduced; in keeping with this
hood, the bones are independent, gradually fus- the temperature falls, respiration is reduced,
ing together by sutures, and in old age fusing cardiac output, heart rate, and blood pressure
completely so that the cranium forms a solid fall, and activity of the sympathetic nervous sys-
bony case. At the time of birth the growth of tem is reduced. NREM sleep normally occurs at
several bones of the infants head has not been the onset of sleep except in neonates. During
quite completed, so that six soft spots, or fonta- adult life, the duration particularly of stages 3
nellas, present; here the brain is covered only by and 4 of NREM sleep becomes less, and very
skin and membranes, and the pulsations of its little of this deep sleep occurs after the age of 60
blood vessels may be seen. One of these spots, years.
the anterior fontanelle, does not close com- NREM sleep has been thought to have sev-
pletely until the child is 18 months to 2 years eral functions, such as energy conservation and
old. growth. Growth hormone is produced in bursts
during stages 3 and 4, and more cell division
Parts of the skull The cranium, enclosing occurs during this type of sleep than during
the brain, consists of eight bones, while the wakefulness. A controversial proposal has been
face, which forms a bony framework for the that processing of information acquired during
eyes, nose and mouth, consists of 14 bones. wakefulness occurs during NREM sleep.
These two parts can be detached.
Rapid-eye-movement (REM) sleep
Shape of the skull The development of This is characterised by the presence of rapid
eye movements and a reduction in muscle tone.
large central hemispheres of the brain in
Cerebral cortical activity is prominent and its
humans has influenced the skull shape. Unlike
blood flow increased. This activity is, however,
in other mammals, the cranium extends above
different from wakefulness and may cause
as well as behind the face which therefore
looks forwards. The skulls proportions
irregular movements of the body as well as of S
the eyes. Most dreams occur in REM sleep:
change with age: the cranium in children is
these may represent a process of reorganising
larger in comparison with the face one-
mental associations after the period of wakeful-
eighth of the whole head than is the case in
ness. The analysis of the content of dreams has
adults, where sizes are about the same. Old
been subject to a variety of interpretations, but
age reduces the size of the face because of the
no consensus view has evolved.
loss of teeth and absorption of their bony
Physiological changes, such as a fall in tem-
sockets. Womens skulls tend to be lighter
perature and blood pressure, take place just
and smoother with less obvious protuberances
before sleep and continue during the early
than those in men.
stages of NREM sleep. There is an intrinsic
rhythm of sleep which in most subjects has a
Slapped Cheek Syndrome periodicity of around 25 hours. This can be
See ERYTHEMA Erythema infectiosum. modified by external factors to bring it into line
with the 24-hour day. Two peaks of a tendency
SLE to sleep have been identified, and these usually
See SYSTEMIC LUPUS ERYTHEMATOSUS (SLE). occur between around 14.0018.00 hours, and
 652 Sleep Apnoeas

02.0006.00 hours. There are, however, differ- Initial treatment is directed at correcting the
ences according to age, in that, for instance, cause (e.g. obesity), but if the apnoeas persist or
infants sleep for most of the 24 hours; during are severe a nasal mask and pump which intro-
adolescence there is also an increase in the dur- duces air under slight pressure into the upper
ation of sleep. Sleep requirements fall later airway (continuous positive airway pressure,
in life, but there are wide genetic differences CPAP) is almost invariably effective.
in the amount of sleep that people require and
also the time at which they fall asleep most Sleep, Disorders of
readily. There are three main groups of SLEEP disorders:
The internal clock can be disturbed by a var-
iety of external factors which include irregular Parasomnias These include medical dis-
sleeping habits due, for instance, to shift work orders such as ASTHMA, ANGINA PECTORIS or
or jet lag. Sleep is also more likely to occur after EPILEPSY which are made worse by sleep, and a
physical exertion, reading and social activity. range of behavioural alterations which are usu-
The duration and intensity of exposure to light ally related to a specific sleep stage or to a
can also modify sleep profoundly. Light pro- change from one state of sleep to another.
motes wakefulness and is the main factor that Sleepwalking, night terrors, and nightmares are
adjusts the 25-hour internal rhythm to the 24- examples.
hour daily cycle. Neural connections from the
retina of the EYE act on an area in the brain Insomnia Insomnia is defined as a difficulty
called the supra-chiasmatic nucleus which in initiating or maintaining sleep. It affects
stimulates the pineal gland which produces around 15 per cent of the population at any one
MELATONIN. This is thought to trigger the time, and is often due to a poor pre-sleep
range of neurological and metabolic processes routine (e.g. taking excessive stimulants such as
that characterise sleep. caffeine); unsatisfactory sleep due to poor
environments such as an uncomfortable bed or
Sleep Apnoeas a cold or noisy bedroom; anxiety and/or depres-
A sleep apnoea is conventionally defined as the sion; or occasionally to a physical problem for
cessation of breathing for ten seconds or more. example, pain or a medical disorder associated
Apnoeas, which affect around 5 per cent of with sleep such as obstructive SLEEP APNOEAS or
adults and are markedly more common in men, periodic limb movements.
may occur as frequently as 400 times per night.
They can be due to a failure of the physiological Excessive daytime sleepiness This is
drive to breathe (central sleep apnoeas) but usually due to sleep deprivation caused either
much more often are due to a transient obstruc- by inadequate duration of sleep, or by poor
tion of the airway between the level of the soft quality of sleep. The individuals lifestyle is
PALATE and the LARYNX (obstructive sleep often a cause and modification of this may
apnoeas) when the airway dilator muscles over- relieve the problem. Other common causes of
relax. Any factor such as alcohol or sedative excessive daytime sleepiness are depression,
drugs that accentuates this, or that makes the obstructive sleep apnoeas, periodic limb move-
airway narrower (such as obesity or large TON- ments, excessive alcohol or other drug intake,
S SILS), will tend to cause sleep apnoeas. and, less commonly, NARCOLEPSY.
Vigorous respiratory movements are made to
overcome the obstruction during each apnoea. Sleeping Sickness
These are associated with snoring and snorting There are two major forms of the disease:
noises. The apnoea ends with a mini-arousal Trypanosoma brucei gambiense is confined to
from sleep. As a result, sleep becomes frag- west and central Africa, and T.b. rhodesiense to
mented and sleep deprivation, manifested as central, east, and south-east Africa. The infec-
sleepiness during the day, is common. This may tion is caused by the bite of tsetse fly (Glossina
result in accidents for instance, at work or spp.). Clinically, a trypanosomal CHANCRE may
while driving and sleep apnoea is also linked develop at the site of the tsetse-fly bite. After
with an increased risk of STROKE, heart attacks introduction into the bloodstream, the parasite
and HYPERTENSION. develops in blood and lymphatic glands. After
The diagnosis of sleep apnoea has recently the blood stage, it enters the central nervous
been facilitated by linking specially designed system, causing characteristic neurological
software with ELECTROCARDIOGRAPHY per- sequelae (see below). Infection may be followed
formed during sleep, with minimal disturbance by a generalised macular papular reaction. In
of the subject. T.b. gambiense infection, enlarged glands in the
 Smell 653

neck (Winterbottoms sign) may be striking. underlying tissues. The process of separation of
Onset of disease is accompanied by fever, pro- a slough is described under gangrene.
gressive ANAEMIA, and enlarged glands; these
signs and symptoms are followed by increasing Small-Bowel Transplantantion
lethargy, slowing of mentality, and physical Before the advent of small-bowel transplants,
weakness, and give way to headache and an long-term intravenous feeding (total parenteral
increasing tendency to sleep. These symptoms nutrition or TPN) was the last option for
are caused by proliferation of parasites in the patients with chronic intestinal failure. Most
patients cerebral blood vessels; this is accom- recipients are children, and small-bowel trans-
panied by inflammatory changes and disorgan- plantation is currently reserved for patients
isation of nervous tissue. Patients become ema- unable to continue on long-term parenteral
ciated and develop bed sores. Death finally nutrition. The main constraints to small-bowel
takes place either as a result of gross emaciation transplantation are the intensity of rejection
or of an intercurrent infection. (necessitating high levels of immunosuppres-
Diagnosis is by detection of trypanosomes in sion), and the lack of donors who are the same
a blood specimen or, alternatively, a sample of size as the recipient (a particular problem for
cerebrospinal fluid. Serological tests are of great children).
value in diagnosis.
Treatment is with suramine or pentamidine; Small-Cell Carcinoma
when cerebral involvement has ensued, melar- See OAT CELL.
soprol which penetrates the blood-brain bar-
rier is of value. In T.b. gambiense infection, Smallpox
eflornithine has recently given encouraging So-called to distinguish the disease from syph-
results; however, this form of CHEMOTHERAPY ilis, the great pox (pox being the plural of pock,
is not effective in a T.b. rhodesiense infection. the Old English term for a PUSTULE), is also
From the point of view of prevention, control known as variola (from varus, the Latin for
of the tsetse-fly population is crucial; even so, pimple). It is an acute, highly infectious disease
only a very small percentage of these vectors is due to a virus. Once it was one of the major
infected with Trypanosoma spp. killing diseases; however, in the 1960s the
World Health Organisation undertook an
Sling eradication scheme by means of mass VACCIN-
A hanging bandage for the support of injured or ATION. As a result, the last naturally occurring
diseased parts. Slings are generally applied for case was recorded in October 1977, and on 8
support of the upper limb, in which case the May 1980 the World Health Assembly con-
limb is suspended from the neck. The lower firmed that smallpox has finally been eradicated
limb may also be supported in a sling from an from the world.
iron cage placed upon the bed on which the
patient lies, the object usually being to aid the Smegma
circulation, and so quicken the healing of ulcers A thick, cheesy secretion formed by the
on the leg. SEBACEOUS GLANDS of the glans penis (see
PENIS). A bacillus, closely resembling the
Slipped Disc tubercle bacillus morphologically, develops S
The popular name for a PROLAPSED INTER- readily in this secretion.
VERTEBRAL DISC. (See also SPINAL COLUMN;
SCIATICA.) Smell
The sense of smell is picked up in what is
Slough known as the olfactory areas of the NOSE.
Slough (pronounced sluff) is dead tissue separ- Each of these is about 3 square centimetres in
ated by natural processes from the living body. area and contains 50 million olfactory, or
The term is applied to hard external parts smelling, cells. They lie, one on either side, at
which the lower animals cast off naturally in the the highest part of each nasal cavity. This is
course of growth, like the skin of snakes or the why we have to sniff if we want to smell any-
shell of crabs. In humans, however, the process thing carefully, as in ordinary quiet breathing
is generally associated with disease, and is then only a few eddies of the air we breathe in
known as GANGRENE. Sloughs may be of very reaches an olfactory area. From these olfactory
small size, as in the case of the core of a boil, or cells the olfactory nerves (one on each side)
they may include a whole limb; but in general a run up to the olfactory bulbs underneath the
slough involves a limited area of skin or of the frontal lobe of the BRAIN, and here the
 654 Smoke Inhalation

impulse is translated into what we describe as Snellen Chart

smell. The most commonly used chart for testing the
acuity of distant VISION. The chart comprises
Smoke Inhalation rows of capital letters, with the letters in each
Smoke is made up of small particles of carbon row being smaller than those in the one above.
in hot air and gases. The particles are covered The top line of large letters can be seen by a
with organic chemicals and smoke may also normally sighted person standing 60 metres
contain carbon monoxide and acids. When away. The subject under test sits 6 metres from
smoke is inhaled, the effects on breathing may the screen and, if he or she can read the 6-metre
be immediate or delayed, depending upon the line of letters, his or her visual acuity is normal
density of smoke and its composition. Laryn- at 6/6.
geal stridor (obstruction of the LARYNX), lack of
oxygen and PULMONARY OEDEMA are life- Snoring
threatening symptoms that require urgent This is usually attributed to vibrations of the
treatment. Immediate removal of the victim soft PALATE, but there is evidence that the main
from the smoke is imperative, as is the adminis- fault lies in the edge of the posterior pillars of
tration of oxygen. The victim may require the FAUCES which vibrate noisily. Mouth-
admission to an intensive-care unit. breathing is necessary for snoring, but not all
mouth-breathers snore. The principal cause is
Smoking blockage of the nose, such as occurs during the
See TOBACCO. course of the common cold or chronic nasal
CATARRH; such blockage also occurs in some
Smooth Muscle cases of deviation of the nasal SEPTUM or nasal
Muscle under the involuntary control of the polypi (see NOSE, DISORDERS OF). In children,
autonomic nervous system (see MUSCLE; NER- mouth-breathing, with resulting snoring, is
VOUS SYSTEM). often due to enlarged TONSILS and adenoids. A
further cause of snoring is loss of tone in the
Snake-Bite soft palate and surrounding tissues due to
See BITES AND STINGS. smoking, overwork, fatigue, obesity, and gen-
eral poor health. One in eight people are said to
Snapping Finger snore regularly. The intensity, or loudness, of
See TRIGGER FINGER. snoring is in the range of 4069 decibels.
(Pneumatic drills register between 70 and 90
Sneezing decibels.) Bouts of snoring sometimes alternate
A sudden expulsion of air through the NOSE, with SLEEP APNOEAS.
designed to expel irritating materials from the Treatment therefore consists of the removal
upper air passages. In sneezing, a powerful of any of these causes of mouth-breathing that
expiratory effort is made; the vocal cords (see may be present. Should this not succeed in pre-
VOICE AND SPEECH; LARYNX) are kept shut until venting snoring, then measures should be taken
the pressure in the chest has risen high; and air to prevent the sufferer from sleeping lying on
is then suddenly allowed to escape upwards, his or her back, as this is a habit strongly con-
S being directed into the back of the nose by the ducive to snoring. Simple measures include
soft PALATE. One sneeze projects 10,000 to sleeping with several pillows, so that the head is
100,000 droplets a distance of up to 10 metres raised quite considerably when asleep; alter-
at a rate of over 60 kilometres an hour. As such natively, a small pillow may be put under the
droplets may contain micro-organisms, it is nape of the neck. If all these measures fail it
clear what an important part sneezing plays in may be worth trying the traditional method of
transmitting infections such as the COMMON sewing a hairbrush, or some other hard object
COLD. Alhough usually transitory, sneezing such as a stone, into the back of the snorers
may persist for days on end up to 204 days pyjamas. Thus, if they turn on their back, they
have been recorded. are quickly awakened. (See also STERTOR.)
Sneezing may be caused by the presence of
irritating particles in the nose, such as snuff, Snow Blindness
or the pollen of grasses and flowers. It is also Damage caused to the cornea of an unprotected
an early symptom of colds, INFLUENZA, MEA- EYE by the reflection of the suns rays from
SLES, and HAY FEVER, being then accompanied snow. ULTRAVIOLET RAYS (UVR) are the dam-
or followed by running at the nose aging agent and people going out in snow and
(RHINITIS). sunlight should wear protective goggles. The
 Sodium Valproate 655

condition is painful but resolves if the eyes are Sodium Aurothiomalate

covered with pads for a day or two. Prolonged A gold compound given by deep intramuscular
exposure may seriously damage the cornea and injection in the treatment of RHEUMATOID
impair vision. ARTHRITIS in children and adults. Known as a
second-line or disease-modifying antirheuma-
Snuffles toid drug, its therapeutic effect may take up to
The traditional name applied to noisy breath- six months to achieve a full response. If this fails
ing in children due to the constant presence of to happen, the drug should be stopped. If the
nasal discharge. (For treatment, see under NOSE, patient responds, treatment may be continued
DISORDERS OF.) at increasingly long intervals (up to four weeks)
for as long as five years. Gold treatment is par-
Social Classes ticularly useful for palindromic arthritis in
As factors such as the cause of death and the which the disease comes and goes.
incidence of diseases vary in different social
strata, the Registrar-General evolved the follow- Sodium Chloride
ing social classification, which has now been in The chemical name for common salt (see
official use for many years: SODIUM).

Class I Professional occupations, such as law- Sodium Cromoglycate

yers, clergymen, and commissioned officers in Used in the prophylaxis of ASTHMA, it is admin-
the Armed Forces. istered by inhalation and can reduce the inci-
dence of asthmatic attacks but is of no value in
the treatment of an acute attack. It acts by pre-
Class II Intermediate occupations, such as
venting the release of pharmacological medi-
teachers, managers and nurses.
ators of BRONCHOSPASM, particularly HIS-
TAMINE, by stabilising mast-cell membranes. It
Class III N: non-manual for example, cler- is of particular use in patients whose asthma has
ical workers. an allergic basis; children over four may
respond better than adults. It is less potent than
Class III M: skilled manual occupations such inhaled steroids. The dose frequency is adjusted
as miners and bricklayers. to the patients response but is usually adminis-
tered by inhalation four times daily. Sodium
Class IV Partly skilled occupations, such as cromoglycate is also used in the prophylaxis of
agricultural workers. allergic RHINITIS and to treat allergic con-
junctivitis (see under EYE, DISORDERS OF).
Class V Unskilled occupations, such as build-
ing and dock labourers. Sodium Diatrizoate
An organic iodine salt that is radio-opaque and
therefore used as a contrast medium to outline
Social Medicine various organs in the body in X-ray films (see X-
See PUBLIC HEALTH.
RAYS). It is given intravenously. Its main use is
in PYELOGRAPHY that is, in rendering the kid- S
Sodium neys radio-opaque but it is also used to
A metal, the salts of which are white, crystal- outline the blood vessels (ANGIOGRAPHY)
line, and very soluble. The fluids of the body and the gall-bladder and bile ducts
contain naturally a considerable quantity of (CHOLANGIOGRAPHY).
sodium chloride.
Sodium Hypochlorite
Sodium carbonate, commonly known as A disinfectant by virtue of the fact that it gives
soda or washing soda, has a powerful softening off chlorine. For domestic use as, for example,
action upon the tissues. for sterilising baby feeding bottles it is avail-
able in a variety of proprietary preparations.
Sodium bicarbonate, or baking soda, is
used as an antacid (see ANTACIDS) in relieving Sodium Valproate
indigestion associated with increased acidity of A drug of first choice for the treatment of
the gastric secretion. several forms of EPILEPSY, including primary
The citrate and the acetate of sodium are generalised epilepsy, generalised absences and
used as DIURETICS. myoclonic seizures; it may also be tried in
 656 Sodomy

atypical absence, atonic and tonic seizures. ERANCE to the volatile substances may develop
Usually taken orally, the drug has shown prom- over months, but acute intoxication may lead to
ising initial results from controlled trials in par- aggressive and impulsive behaviour. Treatment
tial epilepsy. It probably has similar efficacy to of addiction is difficult and requires profes-
CARBAMAZEPINE and PHENYTOIN SODIUM. sional counselling. Victims with acute symp-
Sodium valproate has widespread metabolic toms require urgent medical attention. In Brit-
effects and may have dose-related side-effects. ain, most solvent misusers are males under 20
There has been concern over severe hepatic or years of age. Around 150 deaths occur every
pancreatic toxicity, but such adverse effects are year. (See also DEPENDENCE.)
rare. Other adverse effects include digestive
upsets, drowsiness, muscle incoordination and Somatic
skin rashes. Rare reports have been given of (1) A term describing tissues of the body that
behavioural disturbances, with occasional do not form any part of the reproductive pro-
aggression. Initiation and withdrawal of treat- cess. A somatic MUTATION cannot be passed on
ment should always be slow. Patients should to the next generation.
reduce their alcohol intake; any other drugs (2) It is also used to refer to the body rather
they are taking that are metabolised by the liver than the mind (see PSYCHOSOMATIC DISEASES).
should be carefully monitored.
Somatoform Diseases
Sodomy A group of disorders in which the affected indi-
Sexual intercourse in which the penis penetrates viduals suffer from repeated physical symptoms
the anus and the rectum. Sodomy may occur for which no physical cause can be discovered.
between men, between a man and a woman, or Somatisation is the process by which a persons
between a man and an animal (bestiality). psychological needs are expressed in the form of
physical symptoms. (See also PSYCHOSOMATIC
Solar Plexus DISEASES.)
A large network of sympathetic nerves and gan-
glia situated in the abdomen behind the stom- Somatostatin
ach, where it surrounds the coeliac artery. Also known as the growth-hormone-release-
Branches of the VAGUS nerve the most inhibiting factor, this is a hormone secreted by
important part of the PARASYMPATHETIC NER- the HYPOTHALAMUS and some non-nervous tis-
VOUS SYSTEM lead into the solar plexus,
sues (including the gastrointestinal tract and
which in turn distributes branches to the stom- pancreas). It stops the pituitary-releasing som-
ach, intestines and several other abdominal atotrophin GROWTH HORMONE. Somatosta-
organs. A severe blow in the solar plexus may tin and growth-hormone-releasing hormone are
cause temporary unconsciousness. controlled by complicated neural mechanisms
linked to exercise, sleep patterns, stress,
NEUROTRANSMITTERS and blood GLUCOSE.
Solution
A liquid preparation containing one or more Somatotype
soluble drugs, usually dissolved in water. The physical build of a person. Attempts have
been made to link body build with personality
S Solvent Abuse (Misuse) type, but with no great success. One approach
Also known as volatile-substance abuse, this is is to classify people as endomorphs (heavy phys-
the deliberate inhalation of intoxicating fumes ique and sociable personality); mesomorphs
given off by some volatile liquids. Glue-sniffing (strong, muscular build with well-developed
was the most common type of solvent abuse, bones linked with a physically adventurous
but inhalation of fuel gases such as butane, temperament); and ectomorphs (thin and
especially in the form of lighter refills, is now a lightly built with an introspective nature).
greater problem and has become common
among children particularly teenagers. Solv- Somnambulism
ents or volatile substances are applied to a piece Sleep-walking. (See SLEEP.)
of cloth or put into a plastic bag and inhaled,
sometimes until the person loses consciousness. Soporifics
He or she may become acutely intoxicated; Soporifics are measures which induce SLEEP.
chronic abusers may suffer from ulcers and (See also HYPNOTICS.)
rashes over the face as well as damage to per-
ipheral nerves. Death can occur, probably as a Sore
result of an abnormal rhythm of the heart. TOL- Sore is a popular term for ULCER.
 Specialist 657

Sore Throat contraction of a muscle or of a hollow organ

A raw sensation at the back of the throat. A with a muscular wall. Spasm may be due to
common symptom, the cause is usually PHA- affections in the muscle where the spasm takes
RYNGITIS, sometimes TONSILLITIS. It is often place, or it may originate in some disturbance
the presenting symptom of colds, INFLUENZA, of that part of the nervous system which con-
LARYNGITIS and infectious MONONUCLEOSIS. trols the spasmodically acting muscles. Spasms
Sore throats caused by streptococcal infection of a general nature are usually spoken of as
(see STREPTOCOCCUS) should be treated with CONVULSIONS; spasms of a painful nature are
antibiotics, as should other bacteria-initiated known as cramp (see under MUSCLES, DISORDERS
sore throats; otherwise, symptomatic treatment OF) when they affect the muscles of the limbs,
with analgesics and antiseptic gargles is suf- and as COLIC when they are situated in the
ficient for this usually self-limiting condition. stomach, intestines, ureters or bile duct, or
other organs of the abdomen. Spasm of the
Sotalol heart is called ANGINA PECTORIS, and is both a
See BETA-ADRENOCEPTOR-BLOCKING DRUGS. serious and an agonising condition. When the
spasm is a prolonged firm contraction, it is
Sound spoken of as tonic spasm; when it consists of a
A rod with a curve at one end used to explore series of twitches or quick alternate contractions
body cavities such as the bladder, or to dilate and relaxations, it is known as clonic spasm.
strictures in the urethra or other channels in the Spasm is a symptom of many diseases.
body. (See URINARY BLADDER, DISEASES OF.)
Spasmodic Torticollis
Soya Bean A chronic condition in which the neck is
The bean of Glycine soja, a leguminous plant rotated or deviated laterally, forwards, or back-
related to peas and beans. It has a high protein wards, often with additional jerking or tremor.
and fat content. Starch is almost completely It is a form of focal DYSTONIA, and should not
absent and there is much mineral matter, for be confused with the far commoner transient
example a variable but large amount of iron: 67 condition of acute painful wry-neck.
to 30 mg per 100 grams of soya flour compared
with 1 mg in white flour and 3 mg in 100 Spastic
grams of wholemeal flour. It is a good source of A term applied to any condition showing
thiamine and riboflavine, and of vitamin A in increased muscle tone: for example, spastic gait,
the form of carotene. It is used in infant formu- or spastic colon (see IRRITABLE BOWEL SYN-
las, especially for those babies thought to have DROME (IBS)). This is especially associated with
cows milk protein intolerance. some disease affecting the upper part of the
NERVOUS SYSTEM connected with movement
Space Medicine (upper neuron), so that its controlling influ-
A medical specialty dealing with the physio- ence is lost and the muscles become
logical, PSYCHOLOGICAL and pathological con- overexcitable.
sequences of space flight in which the body has
to cope with unusual variations in gravitational Spatula
forces, including weightlessness, a constricted A flat, knife-like instrument used for spreading S
environment, prolonged close contact with plasters and ointments, and also for depressing
work colleagues in very demanding technical the tongue when the throat is being examined.
circumstances, and sustained periods of emo-
tional pressure including fear. Enormous pro- Specialist
gress has been made in providing astronauts A doctor or other health professional who has
with as normal an environment as possible, and trained to develop a particular skill: for
they have to undergo prolonged physical and example, surgery, cardiac medicine, accident
mental training before embarking on space and emergency care, care of the ageing, or radi-
travel. ology. As new medical techniques and treat-
ments are developed, so new specialties evolve
Spanish Fly to provide them. Specialists have to pass recog-
A popular term for cantharides, which is used as nised examinations as well as be certified that
a blistering agent. they have undergone appropriate education
and hands-on training. Once qualified, they
Spasm are expected to continue their education and
An involuntary, and, in severe cases, painful training to ensure that their skills are kept
 658 Specificity

up-to-date. For doctors, the GENERAL MEDICAL with subsequent help in communication.
COUNCIL (GMC), which is responsible for over- Severe psychiatric disturbance may be accom-
seeing the training and registration of all med- panied by impaired social and communication
ical doctors in the UK, also notes in its annual skills. (See also VOICE AND SPEECH.)
Medical Register those doctors who have com-
pleted appropriate specialist training. Doctors Treatment The underlying cause of the prob-
who have qualified and trained overseas have to lem should be diagnosed as early as possible;
pass appropriate GMC tests before they can psychological and other specialist investigations
practise in the UK. should be carried out as required, and any phys-
ical defect should be repaired. People who are
Specificity deaf and unable to speak should start training
An epidemiological term (see EPIDEMIOLOGY) in lip-reading as soon as possible, and special
describing the extent to which a SCREENING educational methods aimed at acquiring a
TEST for the presence of the precursors of dis- modulated voice should similarly be started in
ease for example, pre-malignant cells in the early childhood provided by the local author-
cervix throws up false positives. A specific test ity, and continued as required. Various types of
has few false positives. speech therapy or PSYCHOTHERAPY may be
appropriate, alone or in conjunction with other
Speculum treatments, and often the final result may be
An instrument designed to aid the examination highly satisfying, with a good command of
of the various openings on the surface of the language and speech being obtained.
body. Many specula are provided with small Help and advice may be obtained from AFA-
electric lamps so placed as to light up the cavity SIC (Unlocking Speech and Language).
of the mouth, ear, nose, rectum or vagina.
Speech Therapy
Speech Disorders Professionally trained speech therapists assist,
These may be of physical or psychological ori- diagnose and treat the whole spectrum of
gin or a combination of both. Difficulties acquired or developmental communication
may arise at various stages of development: due disorders. They work in medical and education
to problems during pregnancy; at birth; caused establishments, often in an advisory or con-
by childhood illnesses; or as a result of delayed sultative capacity. The medical conditions in
development. Congenital defects such as CLEFT which speech therapy is employed include: dys-
PALATE or lip may make speech unintelligible graphia, DYSLEXIA, DYSARTHRIA, DYSPHASIA,
until major surgery is performed, thus dis- DYSPHONIA, DYSPRAXIA, AUTISM, BELLS PALSY,
couraging talking and delaying development. CEREBRAL PALSY, DEAFNESS, disordered lan-
Recurrent ear infections may make hearing dif- guage, delayed speech, disordered speech,
ficult; the childs experience of speech is thus DOWNS (DOWN) SYNDROME, LARYNGECTOMY,
limited, with similar results. Childhood DYS- LEARNING DISABILITY, MACROGLOSSIA, MOTOR
PHASIA occurs if the language-development area NEURONE DISEASE (MND), malformations of the
of the BRAIN develops abnormally; specialist PALATE, PARKINSONISM, STAMMERING, STROKE
education and SPEECH THERAPY may then be and disorders of voice production.
S required. Speech therapists form a small independent
Dumbness is the inability to pronounce the profession, most of whom work for the
sounds that make up words. DEAFNESS is the National Health Service in community clinics,
most important cause, being due to a con- general practices and hospitals. They may also
genital brain defect, or acquired brain disease, work in schools or in units for the handicapped,
such as tertiary SYPHILIS. When hearing is nor- paediatric assessment centres, language units
mal or only mildly impaired, dumbness may be attached to primary schools, adult training
due to a structural defect such as tongue-tie or centres and day centres for the elderly.
enlarged tonsils and adenoids, or to inefficient A speech therapist undergoes a four-year
voice control, resulting in lisping or lalling. degree course which covers the study of dis-
Increased tension is a common cause of STAM- orders of communication in children and
MERING; speech disorders may occasionally be adults, phonetics and linguistics, anatomy and
of psychological origin. physiology, psychology and many other related
Normal speech may be lost in adulthood as a subjects. Further information on training can
result of a STROKE or head injury. Excessive use be obtained from the College of Speech
of the voice may be an occupational hazard; and Therapists.
throat cancer may require a LARYNGECTOMY, If the parents of a child are concerned about
 Sphygmomanometer 659

their childs speech, they may approach a spermatozoon travels at a rate of 153 milli-
speech therapist for assessment and guidance. metres a minute and remains mobile for several
Their general practitioner will be able to give days after insemination, but quickly loses its
them local addresses or they should contact the potency for fertilisation. As it takes only about
district speech therapist. Adults are usually 70 minutes to reach the ovarian end of the uter-
referred by hospital consultants. ine tube, it is assumed that there must be factors
The College of Speech Therapists keeps a other than its own mobility, such as contraction
register of all those who have passed a recog- of the muscle of the womb and uterine tube,
nised degree or equivalent qualification in that speed it on its way.
speech therapy. It will be able to direct you to
your nearest NHS or private speech therapist. Spermicide
Contraceptive preparations that kill sperm.
Sperm They may be in the form of gels, pessaries,
See SPERMATOZOON. cream or foam and should be used with a bar-
rier contraceptive such as a diaphragm or a
Spermatic condom. (See CONTRACEPTION.)
The name applied to the blood vessels and
other structures associated with the TESTICLE. Sphenoid
A bone lying in the centre of the base of the
Spermatic Cord SKULL, and supporting the others like a wedge
This comprises the VAS DEFERENS, nerves and or keystone.
blood vessels, and it runs from the cavity of the
ABDOMEN to the TESTICLE in the SCROTUM. Sphincter
A circular muscle which surrounds the opening
Spermatogenesis from an organ, and, by maintaining a constant
The production of mature sperm (see SPERM- state of moderate contraction, prevents the
ATOZOON) in the testis (see TESTICLE). The escape of the contents of the organ. Sphincters
sperm cells originate from the outermost layer close the outlet from the URINARY BLADDER and
of the seminiferous tubules in the testis: these RECTUM, and in certain nervous diseases their
multiply throughout reproductive life and are action is interfered with, so that the power to
transformed into mature spermatozoa, a process relax or to keep moderately contracted is lost,
that takes up to 80 days. and retention or INCONTINENCE of the evacu-
ation results.
Spermatorrhoea
The passage of SEMEN without erection of the Sphygmograph
PENIS or ORGASM. An instrument for recording the PULSE.

Spermatozoa Sphygmomanometer
See SPERMATOZOON. The traditional device for measuring blood
pressure in clinical practice, devised by Riva-
Spermatozoon Rocci and Korotkoff about a century ago.
(Plural: spermatozoa.) This is the male sex or Measurement depends on accurate transmission S
germ cell which unites with the OVUM to form and interpretation of the pulse wave to an
the EMBRYO or fetus. It is a highly mobile cell artery. The sphygmomanometer is of two types,
approximately 4 micrometres in length much mercury and aneroid. The former is more
smaller than an ovum, which is about 35 accurate. Both have some features in common
micrometres in diameter. Each millilitre of an inflation-deflation system, an occluding
SEMEN contains on average about 100 million bladder encased in a cuff, and the use of AUS-
spermatozoa, and the average volume of semen CULTATION with a STETHOSCOPE. The mercury
discharged during ejaculation in sexual inter- sphygmomanometer consists of a pneumatic
course is 24 ml. (Some recent research suggests armlet which is connected via a rubber tube
that male fertility is falling because of a with an air-pressure pump and a measuring
reduction in the production of viable spermato- gauge comprising a glass column containing
zoa possibly due to environmental factors, mercury. The armlet is bound around the upper
including the discharge of hormones used for arm and pumped up sufficiently to obliterate
agricultural purposes and for human hormonal the pulse felt at the wrist or heard by ausculta-
contraception.) tion of the artery at the bend of the elbow. The
Once ejaculated during intercourse the pressure, measured in millimetres of mercury
 660 Spina Bifida

(mm Hg), registered at this point on the gauge of surgery which may be in the first few days of
is regarded as the pressure of the blood at each life or much later depending upon the precise
heartbeat (ventricular contraction). This is situation; long-term follow-up is necessary to
called the systolic pressure. The cuff is then pick up any neurological problems that may
slowly deflated by releasing the valve on the air develop during subsequent growth of the spine.
pump and the pressure at which the sound Meningomyelocele is much more serious and
heard in the artery suddenly changes its char- more common, accounting for 90 per cent of
acter marks the diastolic pressure. Aneroid all cases. Usually affecting the lumbo-sacral
sphygmomanometers register pressure through region, the range of severity may vary consider-
an intricate bellows and lever system which is ably and, while early surgery with careful atten-
more susceptible than the mercury type to the tion in a minor case may achieve good mobility,
bumps and jolts of everyday use which reduce normal bladder function and intellect, a more
its inaccuracy. extensive protrusion may cause complete
While mercury sphygmomanometers are ANAESTHESIA of the skin, with increased risk of
simple, accurate and easily serviced, there is trauma; extensive paralysis of the trunk and
concern about possible mercury toxicity for limbs, with severe deformities; and paralysis
users, those servicing the devices and the and insensitivity of the bladder and bowel.
environment. Use of them has already been Involuntary movements may be present, and
banned in some European hospitals. Although hydrocephalus occurs in 80 per cent of cases.
it may be a few years before they are widely The decision to operate can only be made after
replaced, automated blood-pressure-measuring a full examination of the infant to determine
devices will increasingly be in routine use. A the extent of the defect and any co-existent
wide variety of ambulatory blood-pressure- congenital abnormalities. The childs potential
measuring devices are already available and may can then be estimated, and appropriate treat-
be fitted in general practice or hospital settings, ment discussed with the parents. Carefully
where the patient is advised on the technique. selected patients should receive long-term
Blood-pressure readings can be taken half- treatment in a special centre, where full atten-
hourly or more often, if required with little tion can be paid to all their various problems.
disturbance of the patients daily activities There is growing evidence of the value of
or sleep. (See also BLOOD PRESSURE; vitamin supplements before and during preg-
HYPERTENSION.) nancy in reducing the incidence of spina bifida.
Parents of affected infants may obtain help,
Spina Bifida advice, and encouragement from the Associ-
This is one of the most common of the con- ation for Spina Bifida and Hydrocephalus
genital (present at birth) malformations. It is which has branches throughout the country, or
one of the three types of neural-tube anomaly, the Scottish Spina Bifida Association.
the other two being ANENCEPHALY and cranium
bifidum. It takes two main forms spina bifida Spinal Anaesthesia
occulta being much the commoner. There is a See under ANAESTHESIA.
deficit in the posterior part of the SPINAL COL-
UMN, usually in the LUMBAR region, and it is Spinal Column
S generally asymptomatic unless the underlying Also known as the spine, this forms an import-
spinal cord is affected. Occasionally it is associ- ant part of the skeleton, acting both as the rigid
ated with a hairy patch or birthmark on the pillar which supports the upper parts of the
back, and a few children develop a mild spastic body and as a protection to the SPINAL CORD
gait or bladder problems. and nerves arising from it. The spinal column is
Much more serious is spina bifida cystica, in built up of a number of bones placed one upon
which the spinal-wall defect is accompanied by another, which, in consequence of having a
a protrusion of the spinal cord. This may take slight degree of turning-movement, are known
two forms: a meningocele, in which the as the vertebrae. The possession of a spinal cord
MENINGES, containing CEREBROSPINAL FLUID, supported by a vertebral column distinguishes
protrude through the defect; and a meningo- the higher animals from the lower types, and is
myelocele, in which the protrusion contains why they are called vertebrates. Of the ver-
spinal cord and nerves. tebrates, humans alone stand absolutely erect,
Meningocele is less common and has a good and this erect carriage of the body gives to the
prognosis. HYDROCEPHALUS and neurological skull and vertebral column certain distinctive
problems affecting the legs are rare, although characters.
the bladder may be affected. Treatment consists The human backbone is about 70 cm (28
 Spinal Column 661

The atlas (first cervical vertebra) and axis (second cervical vertebra) vertebrae and a lumbar vertebra seen S
from above. (Top) the spinal column.

inches) in length, and varies little in full-grown numbers are expressed in a formula thus: C7,
people; differences in height depend mainly D12, L5, S5, Coc4=33.
upon the length of the lower limbs. The num- Although the vertebrae in each of these
ber of vertebrae is 33 in children, although in regions have distinguishing features, all the ver-
adult life five of these fuse together to form the tebrae are constructed on the same general plan.
sacrum, and the lowest four unite in the coccyx, Each has a thick, rounded, bony part in front,
so that the number of separate bones is reduced known as the body, and these bodies form the
to 26. Of these there are seven in the neck, main thickness of the column. Behind the body
known as cervical vertebrae; 12 with ribs of each is a ring of bone, the neural ring, these
attached, in the region of the thorax known as rings placed one above another forming the
thoracic or dorsal vertebrae; five in the loins, bony canal which lodges the spinal cord. From
called lumbar vertebrae; five fused to form the each side of the ring a short process of bone
sacrum; and four joined in the coccyx. These known as the transverse process stands out, and
 662 Spinal Cord

from the back of the ring a larger process, the attached to the coccyx at the lower end of the
spinous process, projects. These processes give spine. The spinal cord is thus considerably
attachment to the strong ligaments and muscles shorter than the spinal column, being only 37
which unite, support, and bend the column. 45 cm (1518 inches) in length, and weighing
The spines can be seen or felt beneath the skin around 30 grams.
of the back lying in the centre of a groove In its course from the base of the skull to the
between the muscular masses of the two sides, lumbar region, the cord gives off 31 nerves on
and they give to the column its name of the each side, each of which arises by an anterior
spinal column. One of these spines, that of the and a posterior root that join before the nerve
seventh cervical vertebra, is especially large and emerges from the spinal canal. The openings
forms a distinct bony prominence, where the for the nerves formed by notches on the ring of
neck joins the back. Between the bodies of the each vertebra have been mentioned under the
vertebrae lies a series of thick discs of fibro- entry for spinal column. To reach these open-
cartilage known as intervertebral discs. Each ings, the upper nerves pass almost directly out-
disc consists of an outer portion, known as the wards, whilst lower down their obliquity
annulus fibrosus, and an inner core, known as increases, until below the point where the cord
the nucleus pulposus. These 23 discs provide ends there is a sheaf of nerves, known as the
the upper part of the spine with pliability and cauda equina, running downwards to leave the
resilience. spinal canal at their appropriate openings.
The first and second cervical vertebrae are The cord is a cylinder, about the thickness of
specially modified. The first vertebra, known as the little finger. It has two slightly enlarged por-
the atlas, is devoid of a body, but has a specially tions, one in the lower part of the neck, the
large and strong ring with two hollows upon other at the last dorsal vertebra; and from these
which the skull rests, thus allowing forward and thickenings arise the nerves that pass to the
backward movements (nodding). The second upper and lower limbs. The upper four cervical
vertebra, known as the axis, has a pivot on its nerves unite to produce the cervical plexus.
body which fits into the first vertebra and thus From this the muscles and skin of the neck are
allows free rotation of the head from side to mainly supplied, and the phrenic nerve, which
side. The spinal column has four natural curves runs down through the lower part of the neck
(see diagram) which help to cushion the shocks of and the chest to innervate the diaphragm, is
walking and running. given off. The brachial plexus is formed by the
The neural rings of the vertebrae form a union of the lower four cervical and first dorsal
canal, which is wide in the neck, smaller and nerves. In addition to nerves to some of the
almost round in the dorsal region, and wide muscles in the shoulder region, and others to
again in the lumbar vertebrae. Down the canal the skin about the shoulder and inner side of
runs the spinal cord, and the nerves leaving the the arm, the plexus gives off large nerves that
cord do so through openings between the ver- proceed down the arm.
tebrae which are produced by notches on the The thoracic or dorsal nerves, with the
upper and lower margins of each ring. The exception of the first, do not form a plexus, but
intervertebral foramina formed by these each runs around the chest along the lower
notches are so large in comparison with the margin of the rib to which it corresponds,
S nerves passing through them that there is no whilst the lower six extend on to the abdomen.
chance of pressure upon the latter, except in The lumbar plexus is formed by the upper
very serious injuries which dislocate and frac- four lumbar nerves, and its branches are dis-
ture the spine. tributed to the lower part of the abdomen, and
front and inner side of the thigh.
Spinal Cord The sacral plexus is formed by parts of the
This is the lower portion of the CENTRAL NER- fourth and fifth lumbar nerves, and the upper
VOUS SYSTEM which is situated within the three and part of the fourth sacral nerves. Much
SPINAL COLUMN. Above, it forms the direct of the plexus is collected into the sciatic nerves,
continuation of the medulla oblongata, this the largest in the body, which go to the legs.
part of the BRAIN changing its name to spinal The sympathetic system is joined by a pair of
cord at the foramen magnum, the large opening small branches given off from each spinal nerve,
in the base of the skull through which it passes close to the spine. This system consists of two
into the spinal canal. Below, the spinal cord parts, first, a pair of cords running down on the
extends to about the upper border of the second side and front of the spine, and containing on
lumbar vertebra, where it tapers off into a fine each side three ganglia in the neck, and beneath
thread, known as the filum terminale, that is this a ganglion opposite each vertebra. From
 Spine and Spinal Cord, Diseases and Injuries of 663

these two ganglionated cords numerous direct to them through sensory nerves, such
branches are given off, and these unite to form activity being known as REFLEX ACTION. (For a
the second part namely, plexuses connected fuller description of the activities of the spinal
with various internal organs, and provided with cord, see NEURON(E) Reflex action.)
numerous large and irregularly placed ganglia. The posterior column of the cord consists of
The chief of these plexuses are the cardiac the fasciculus gracilis and the fasciculus cunea-
plexus, the solar or epigastric plexus, the dia- tus, both conveying sensory impressions
phragmatic, suprarenal, renal, spermatic, or upwards. The lateral column contains the ven-
ovarian, aortic, hypogastric and pelvic plexuses. tral and the dorsal spino-cerebellar tracts pass-
The spinal cord, like the brain, is surrounded ing to the cerebellum, the crossed pyramidal
by three membranes: the dura mater, arachnoid tract of motor fibres carrying outgoing impulses
mater, and pia mater, from without inwards. downwards together with the rubro-spinal, the
The arrangement of the dura and arachnoid is spino-thalamic, the spino-tectal, and the
much looser in the case of the cord than their postero-lateral tracts. And, finally, the anterior
application to the brain. The dura especially column contains the direct pyramidal tract of
forms a wide tube which is separated from the motor fibres and an anterior mixed zone. The
cord by fluid and from the vertebral canal by pyramidal tracts have the best-known course.
blood vessels and fat, this arrangement protect- Starting from cells near the central sulcus on the
ing the cord from pressure in any ordinary brain, the motor nerve-fibres run down through
movements of the spine. the internal capsule, pons, and medulla, in the
lower part of which many of those coming from
In section the spinal cord consists partly of the right side of the brain cross to the left side of
grey, but mainly of white, matter. It differs from the spinal cord, and vice versa. Thence the
the upper parts of the brain in that the white fibres run down in the crossed pyramidal tract
matter (largely) in the cord is arranged on the to end beside nerve-cells in the anterior horn of
surface, surrounding a mass of grey matter the cord. From these nerve-cells other fibres
(largely neurons see NEURON(E)), while in the pass outwards to form the nerves that go direct
brain the grey matter is superficial. The to the muscles. Thus the motor nerve path from
arrangement of grey matter, as seen in a section brain to muscle is divided into two sections of
across the cord, resembles the letter H. Each neurons, of which the upper exerts a controlling
half of the cord possesses an anterior and a pos- influence upon the lower, while the lower is
terior horn, the masses of the two sides being concerned in maintaining the muscle in a state
joined by a wide posterior grey commissure. In of health and good nutrition, and in directly
the middle of this commissure lies the central calling it into action. (See also NERVE; NERVOUS
canal of the cord, a small tube which is the SYSTEM.)
continuation of the ventricles in the brain. The
horns of grey matter reach almost to the surface Spine and Spinal Cord, Diseases
of the cord, and from their ends arise the roots and Injuries of
of the nerves that leave the cord. The white
matter is divided almost completely into two Scoliosis A condition where the spine is
halves by a posterior septum and anterior fissure curved to one side (the spine is normally
and is further split into anterior, lateral and pos- straight when seen from behind). The deform- S
terior columns. ity may be mobile and reversible, or fixed; if
fixed it is accompanied by vertebral rotation
Functions The cord is, in part, a receiver and and does not disappear with changes in posture.
originator of nerve impulses, and in part a con- Fixed scoliosis is idiopathic (of unknown cause)
ductor of such impulses along fibres which pass in 6580 per cent of cases. There are three main
through it to and from the brain. The cord con- types: the infantile type occurs in boys under
tains centres able to receive sensory impressions three and in 90 per cent of cases resolves spon-
and initiate motor instructions. These control taneously; the juvenile type affects 49 year olds
blood-vessel diameters, eye-pupil size, sweating and tends to be progressive. The most common
and breathing. The brain exerts an overall con- type is adolescent idiopathic scoliosis; girls are
trolling influence and, before any incoming affected in 90 per cent of cases and the inci-
sensation can affect consciousness, it is usually dence is 4 per cent. Treatment may be conserva-
filtered through the brain. tive with a fixed brace, or surgical fusion may be
Many of these centres act autonomously. needed if the curve is greater than 45 degrees.
Other cells of the cord are capable of originat- Scoliosis can occur as a congenital condition
ing movements in response to impulses brought and in neuromuscular diseases where there is
 664 Spiramycin

muscle imbalance, such as in FRIEDREICHS plaint is of pain after exercise. Treatment is bed
ATAXIA. rest in a bad attack with surgery indicated only
if there are worrying signs of cord compression.
Kyphosis is a backward curvature of the
spine causing a hump back. It may be postural Spinal stenosis is due to a narrowing of the
and reversible in obese people and tall ado- spinal canal which means that the nerves
lescent girls who stoop, but it may also be fixed. become squashed together. This causes numb-
Scheuermanns disease is the term applied to ness with pins and needles (paraesthia) in the
adolescent kyphosis. It is more common in legs. COMPUTED TOMOGRAPHY and nuclear
girls. Senile kyphosis occurs in elderly people magnetic resonance imaging scans can show the
who probably have osteoporosis (bone weaken- amount of cord compression. If improving pos-
ing) and vertebral collapse. ture does not help, surgical decompression may
be needed.
Disc degeneration is a normal con-
sequence of AGEING. The disc loses its resiliance Whiplash injuries occur to the neck, usu-
and becomes unable to withstand pressure. ally as the result of a car accident when the head
Rupture (prolapse) of the disc may occur with and neck are thrown backwards and then for-
physical stress. The disc between the fourth and wards rapidly. This causes pain and stiffness in
fifth lumbar vertebrae is most commonly the neck; the arm and shoulder may feel numb.
involved. The jelly-like central nucleus pulpo- Often a support collar relieves the pain but
sus is usually pushed out backwards, forcing the recovery commonly takes between 18 months
annulus fibrosus to put pressure on the nerves to three years.
as they leave the spinal canal. (See PROLAPSED
INTERVERTEBRAL DISC.) Transection of the cord occurs usually as
a result of trauma when the vertebral column
Ankylosing spondylitis is an arthritic protecting the spinal cord is fractured and
disorder of the spine in young adults, mostly becomes unstable. The cord may be concussed
men. It is a familial condition which starts with or it may have become sheared by the trauma
lumbar pain and stiffness which progresses to and not recover (transected). Spinal concussion
involve the whole spine. The discs and liga- usually recovers after 12 hours. If the cord is
ments are replaced by fibrous tissue, making the transected the patient remains paralysed. (See
spine rigid. Treatment is physiotherapy and PARALYSIS.)
anti-inflammatory drugs to try to keep the
spine supple for as long as possible. Spiramycin
A National Association for Ankylosing One of the MACROLIDES isolated from Strepto-
Spondylitis has been formed which is open to myces ambofaciens which is used under strict
those with the disease, their families, friends conditions for the treatment of
and doctors. TOXOPLASMOSIS.

Spondylosis is a term which covers disc Spirillum

degeneration and joint degeneration in the A form of micro-organism of wavy or spiral
S back. OSTEOARTHRITIS is usually implicated. shape. (See MICROBIOLOGY.)
Pain is commonly felt in the neck and lumbar
regions and in these areas the joints may Spirit
become unstable. This may put pressure on the A strong solution of ALCOHOL in water. Proof
nerves leaving the spinal canal, and in the lum- spirit is one containing 57 per cent of alcohol
bar region, pain is generally felt in the distribu- by volume or 49 per cent by weight, and is so-
tion of the sciatic nerve down the back of the named because it can stand the proof of just
leg. In the neck the pain may be felt down the catching fire. Rectified spirit contains 90 per
arm. Treatment is physiotherapy; often a neck cent of alcohol by volume or over 85 per cent
collar or lumbar support helps. Rarely surgery is by weight. Methylated spirit (also known as
needed to remove the pressure from the nerves. wood naphtha or wood spirit) is distilled from
wood; when taken internally it is a dangerous
Spondylolisthesis means that the spine is poison producing NEURITIS, especially neuritis
shifted forward. This is nearly always in the of the optic nerves which may result in blind-
lower lumbar region and may be familial, or ness. Methylated spirit is used to harden the
due to degeneration in the joints. Pressure may skin for the prevention of bed sores and foot
be put on the cauda equina. The usual com- soreness.
 Spleen 665

Spiritual Pain output of aldosterone in oedematous condi-

Spiritual pain is what may be felt when one of a tions (see OEDEMA) such as congestive heart
persons four key spiritual relationships (with failure, which accentuates the oedema
other people, with oneself, with the world spironolactone is used, along with other
around, or with Life itself ) is traumatised or DIURETICS.
broken. A bad trauma in one of the first three
relationships can lead to damage to the last of Splanchnic
them that of the relationship with Life itself. Anything belonging to the internal organs of
For example, a wife deserted by her husband the body, as distinguished from its framework.
for another woman may not only feel devas-
tated by the loss of her partner around the Spleen
place, but may also feel a pain caused by the An organ deeply placed in the abdomen and a
shattering of her beliefs about life (about faith- major constituent of the RETICULO-
fulness, hope, love, security, etc.). It is as if ENDOTHELIAL SYSTEM.
there is a picture at the centre of each person of
what life should be about whether or not held Position and size The spleen lies behind
in a frame by a belief in God; this picture can the stomach, high up on the left side of the
be smashed by a particular trauma, so that abdomen, and corresponds to the position of
nothing makes sense any more. The individual the ninth, tenth and 11th ribs, from which it is
cannot get things together; everything loses its separated by the diaphragm. It is a soft, highly
meaning. This shattering of someones picture vascular, plum-coloured organ, and has a
of life is the source of the deepest pain in any smooth surface. It is usually about 12515 cm
spiritual trauma. The connection is often made (56 inches) in length, and weighs about 170
between spiritual pain and meaninglessness. If grams or more. In diseased conditions the organ
the shattering of the picture, on the other may reach a weight of 89 kg.
hand, is done by the individual for instance,
by breaking his or her own moral or religious Structure The spleen is enveloped by peri-
code the pain may take the form of guilt and toneal membrane beneath which is a strong
associated feelings. Hence, the therapist will be elastic tunic, composed partly of fibrous tissue
intent upon helping a client to recognise and
come to terms with this pain beneath the
pain.

Spirochaete
An order of bacteria which has a spiral form.
(See MICROBIOLOGY.)

Spirometer
A device to test how the lung is working (see also
PULMONARY FUNCTION TESTS) to assess the
effects of lung disease or the progress of treat-
ment a procedure called spirometry. The spir- S
ometer records the total volume of air breathed
out the forced vital capacity. The machine
also records the volume of air breathed out in
one second the forced expiratory volume. In
diseases such as ASTHMA, in which the airways
are obstructed, the ratio of the forced expiratory
volume to the forced vital capacity is reduced.
(See RESPIRATION.)

Spironolactone
One of the group of substances known as
spirolactones. These are steroids similar to
ALDOSTERONE in structure which competitively
act as inhibitors of it; they can thus antagonise
the action of aldosterone in the renal tubules.
As there is evidence that there is an increased Cross-section of cone of tissue from spleen.
 666 Spleen, Diseases of

Position of spleen in relation to other abdominal organs.

containing many elastic fibres, and partly of Spleen, Diseases of

unstriped muscle. This elastic coat allows of the In certain diseases associated with marked
free expansion and contraction of the organ changes in the blood, such as LEUKAEMIA and
according to the varying amount of blood pres- MALARIA, the SPLEEN becomes chronically
ent in it. From the inner surface of the mem- enlarged. In some of the acute infectious dis-
brane, fibrous partitions known as trabeculae eases, it becomes congested and acutely
run down into the substance and form a enlarged: for example, in typhoid fever (see
network in which the dark spleen pulp is ENTERIC FEVER), ANTHRAX and infectious
contained. The pulp consists of delicate MONONUCLEOSIS. Rupture of the spleen may
connective-tissue fibres passing between the occur, like rupture of other internal organs, in
various trabeculae, and of white and red blood consequence of extreme violence but in mal-
cells lying in this meshwork. The spleen is very arious countries, where many people have the
S vascular and venous blood leaves by the splenic spleen greatly enlarged and softened as the
vein and then enters the portal vein from the result of malaria, rupture of this organ
liver. There are also numerous lymphatics in the occasionally occurs following even a light blow
organ, which run in the trabeculae or surround to the left side of the abdomen. The spleen, in
the veins. consequence of its structure, bleeds excessively
when torn, so that this accident is generally fol-
Functions The organ produces lymphocytes lowed by collapse, signs of internal haemor-
(see LYMPHOCYTE) and acts as a reservoir of red rhage and death if not dealt with promptly by
blood cells for use in emergencies. It is also one operation.
of the sites for the manufacture of red blood
cells in the fetus, but not after birth. Useless or
worn-out red and white blood cells and blood Splenectomy
PLATELETS are broken up by this organ. This Removal of the SPLEEN. This operation may be
results in the production of BILIRUBIN, which is necessary if the spleen has been severely injured,
conveyed to the liver, and of iron, which is used or in the treatment of the severe form of acholu-
in the bone marrow for the production of new ric JAUNDICE or autoimmune thrombocyto-
red blood cells. penic PURPURA.
 Sports Medicine 667

Splenomegaly Sporadic
Enlargement of the SPLEEN beyond its normal The term applied to cases of disease occurring
size. here and there, as opposed to EPIDEMIC
outbreaks.
Splinter Haemorrhages
Linear bleeding under the fingernails. Although Spore
they may result from injury, they are a useful Part of the lifecycle of certain BACTERIA when
physical sign of infective ENDOCARDITIS. the vegetative cell is encapsulated and metabol-
ism falls to a low level. The spore is resistant to
Splints changes in the environment and, when these
Supports for an injured or wounded part. are unfavourable, the spore remains dormant;
They are most commonly employed in cases in when they improve, it starts to grow. Certain
which a bone is fractured, and consist then of dangerous bacteria, such as CLOSTRIDIUM, pro-
some rigid substance designed to take the duce resistant ubiquitous spores, so sterilisation
place of the broken bone in maintaining procedures need to be very effective.
the shape of the limb, as well as to keep the
broken ends at rest and in contact and so Sporozoa
ensure their union. Splints are most com- The name of a group of parasitic PROTOZOA
monly made of wood, either shaped to the which includes the parasitic Plasmodium that
limb or consisting merely of strips of wood causes MALARIA. The life-cycles of sporozoa are
about the width of the injured limb, and care- complex, often with sexual and asexual stages.
fully padded with wool or similar soft
material. Splints are also made of metal, poro- Sporozoites
plastic felt, leather, and cotton stiffened with Sporozoites is one cell type of the many that are
plaster of Paris, as well as other materials. formed during the life-cycle of SPOROZOA. In
Splints may be improvised for first-aid out the case of MALARIA, sporozoites pass into the
of walking-sticks, rifles, broom-handles, salivary glands of the mosquito and and are
branches, folded-up newspapers, and in fact the infecting agent of the human host when the
anything of suitable length and rigidity. (See insect next feeds on human blood.
also BONE, DISORDERS OF Bone fractures.)
Sports Medicine
Spondylitis The field of medicine concerned with physical
Another name for ARTHRITIS of the spine (see fitness and the diagnosis and treatment of both
SPINE AND SPINAL CORD, DISEASES AND INJUR- acute and chronic sports injuries sustained dur-
IES OF). ing training and competition. Acute injuries are
extremely common in contact sports, and their
Spondylolisthesis initial treatment is similar to that of those sus-
See SPINE AND SPINAL CORD, DISEASES AND tained in other ways, such as falls and road traf-
INJURIES OF. fic incidents. Tears of the muscles (see MUSCLES,
DISORDERS OF), CONNECTIVE TISSUE and
Spondylosis LIGAMENTS which are partial (sprains) are ini-
See SPINE AND SPINAL CORD, DISEASES AND tially treated with rest, ice, compression, and S
INJURIES OF. elevation (RICE) of the affected part. Complete
tears (rupture) of ligaments (see diagrams) or
Spongiform Encephalopathy muscles, or fractures (see BONE, DISORDERS OF
A disease of the neurological system caused by a Bone fractures) require more prolonged
PRION. Spongy degeneration of the BRAIN immobilisation, often in plaster, or surgical
occurs with progressive DEMENTIA. Known intervention may be considered. The rehabilita-
examples of the disorder in humans are tion of injured athletes requires special expertise
CREUTZFELDT-JAKOB DISEASE (CJD) and KURU. an early graded return to activity gives the
Among animals, scrapie in sheep and BOVINE best long-term results, but doing too much too
SPONGIFORM ENCEPHALOPATHY (BSE) are soon runs the risk of exacerbating the original
caused by slow viruses. The latter has occurred injury.
as an outbreak in cattle over the past decade or Chronic (overuse) injuries affecting the
so, probably as a result of cattle being fed pro- bones (see BONE), tendons (see TENDON) or
cessed offal from infected animals. Some people BURSAE of the JOINTS are common in many
have developed a form of CJD from eating sports. Examples include chronic INFLAMMA-
infected beef. TION of the common extensor tendon where it
 668 Sports Medicine

Torn ankle ligament.

attaches to the later EPICONDYLE of the

humerus common in throwers and racquet
stimulants such as AMPHETAMINES, broman-
tan, caffeine, carphedon, COCAINE, EPHE-
sportspeople and stress fractures of the TIBIA DRINE and certain beta-2 agonists.
or METATARSAL BONES of the foot in runners.
After an initial period of rest, management
NARCOTICS such as DIAMORPHINE (heroin),
MORPHINE, METHADONE HYDROCHLORIDE
often involves coaching that enables the athlete and PETHIDINE HYDROCHLORIDE.
to perform the repetitive movement in a less
injury-susceptible manner.
ANABOLIC STEROIDS such as methandione,
NANDROLONE, stanazol, TESTOSTERONE,
clenbuterol, androstenedone and certain
Exercise physiology is the science of beta-2 agonists.
measuring athletic performance and physical
fitness for exercise. This knowledge is applied to
peptide HORMONES, mimetics and analogues
such as GROWTH HORMONE, CORTICO-
devising and supervising training regimens TROPHIN, CHORIONIC GONADOTROPHIC
based on scientific principles. Physical fitness HORMONE, pituitary and synthetic GON-
depends upon the rate at which the body can ADOTROPHINS, ERYTHROPOIETIN and
deliver oxygen to the muscles, known as the INSULIN.
VO2max, which is technically difficult to meas- (The list produced above is not comprehen-
ure. The PULSE rate during and after a bout of sive: full details are available from the governing
exercise serves as a good proxy of this bodies of relevant sports.) Among banned
S measurement. methods are blood doping (pre-competition
administration of an athletes own previously
Regulation of sport Sports medicines provided and stored blood), administration of
role is to minimise hazards for participants by, artificial oxygen carriers or plasma expanders.
for example, framing rule-changes which forbid Also forbidden is any pharmacological, chem-
collapsing the scrum, which has reduced the ical or physical manipulation to affect the
risk of neck injury in rugby; and in the detec- results of authorised testing.
tion of the use of drugs taken to enhance ath- Drug use can be detected by analysis of the
letic performance. Such attempts to gain an URINE, but testing only at the time of competi-
edge in competition undermine the sporting tion is unlikely to detect drug use designed to
ideal and are banned by leading sports regula- enhance early-season training; hence random
tory bodies. The Olympic Movement Anti- testing of competitive athletes is also used.
Doping Code lists prohibited substances and The increasing professionalism and com-
methods that could be used to enhance per- petitiveness (among amateurs and juveniles as
formance. These include some prohibited in well as professionals) in sports sometimes
certain circumstances as well as those com- results in pressures on participants to get fit
pletely banned. The latter include: quickly after injury or illness. This can lead to
 Sputum 669

Anterior view of right knee-joint.

players returning to their activity before they ference with the absorption of carbohydrates,
are properly fit sometimes by using physical vitamins, and minerals, leading to anaemia and
or pharmaceutical aids. This practice can HYPOCALCAEMIA.
adversely affect their long-term physical cap-
abilities and perhaps their general health. Symptoms Of gradual or rapid onset, there is
initial weakness, soreness of the tongue, dif-
Spots Before the Eyes ficulty swallowing, indigestion, diarrhoea and
Also called FLOATERS, these can arise from a poor appetite. Anaemia is typically macrocytic,
variety of causes including inflammation and and mild HYPOGLYCAEMIA may occur.
bleeding in the eye, or preceding a retina Untreated, the patient steadily loses weight and,
detachment. They may also occur for a variety unless appropriate treatment is started early,
of totally harmless reasons. (See EYE, DISORDERS death may be expected because of exhaustion
OF.) and some intercurrent infection.

Spotted Fever Treatment This consists of bed rest, a high-

See MENINGITIS; EPIDEMIC; TYPHUS FEVER. protein diet (initially skimmed milk), and
treatment of the anaemia and any other
Sprains deficiencies present. Minimum fat should be
Injuries in the neighbourhood of joints, consist- given to sufferers, who should also take folic
ing usually in tearing of a ligament with effu- acid and cyanocobalamin for the anaemia; large S
sion of blood. (See JOINTS, DISEASES OF.) vitamin-B-complex supplements (such as
Marmite) are helpful. Vitamins A and D,
Sprue together with calcium supplements, help to
A disease occurring most commonly in patients raise the concentration of calcium in the blood.
in or from the tropics, and characterised by A long convalescence is often required, which
diarrhoea with large, fatty stools; ANAEMIA; sore may lead to marked depression, and patients
tongue; and weight loss. Its manifestations should be sent home to a temperate climate.
resemble those of non-tropical sprue, or gluten Non-tropical sprue is the result of GLUTEN
enteropathy, and COELIAC DISEASE. hypersensitivty and is treated with a gluten-free
diet.
Causes Tropical sprue is thought to be due to
an inborn error of metabolism, characterised Sputum
primarily by an inability to absorb fats from the The mucous secretions from the mouth, throat
intestines. Its epidemiological pattern suggests or back of the nose. Sputum is also expectorated
that an infection such as DYSENTERY may be the by coughing from the lower air passages. Its pro-
precipitating factor. Subsequently there is inter- duction may be increased by respiratory-tract
 670 Squill

allergy (ASTHMA) or by breathing-in irritants but temporarily loses the ability to execute lin-
such as tobacco smoke, smoke from a fire, or guistically formulated speech. Stammering is
fumes from chemical materials. Sputum is characterised by a silent or audible involuntary
normally white, but infection will turn it to yel- repetition/prolongation of an utterance, be it a
low or green, and blood from the lungs may sound, syllable or word. Sometimes it is accom-
produce pink frothy sputum. Treatment is to panied by accessory behaviours, or speech-
deal with the underlying disorder. Production related struggle. Usually there are indications or
of large quantities of sputum for instance, in the report of an accompanying emotional
BRONCHIECTASIS may require physiotherapy state, involving excitement, tension, fear or
and postural drainage. (See also embarrassment.
EXPECTORATION.) Idiopathic stammering begins at some time
between the onset of speech and puberty,
Squill mostly between 25 years of age. Acquired
A herbal extract (from a type of lily) that is stammering at a later age due to brain damage is
included in some over-the-counter cough rem- rare. The prevalence of stammering (the per-
edies because of its believed expectorant proper- centage of the population actually stammering
ties (see EXPECTORATION). at any point in time) is approximately 09 per
cent. Three times as many boys as girls stam-
Squint mer. About 70 per cent of stammering children
Squint, or strabismus, is a condition in which recover with little or no therapy. Stammerers
the visual axes of each EYE are not directed sim- have not been shown to demonstrate differ-
ultaneously at the same fixation point (i.e. each ences in personality from non-stammerers;
eye is not pointing at the same object at the there are, however, indications that at least
same time). Squints may be: (a) Paralytic, some stammerers show minimal differences
where one or more of the muscles, or their from fluent speakers in cerebral processing of
nerve supply, is damaged; this type usually verbal material.
results in double vision. (b) Non-paralytic, There is a genetic predisposition towards
where the muscles and nerves are normal. It is stammering. The risk of stammering among
usually found in children. This type of squint first-degree relatives of stammerers is more than
can either result in poor vision, or occasionally three times the population risk. In 77 per cent
may result from poor vision. of identical twins, either both stammer or both
Squints may be convergent (where one eye are fluent. Only 33 per cent of non-identical
turns in) or divergent (one eye turns out). twins agree in this way. As there are identical
Vertical squints can also occur but are less twins who differ for stammering, environ-
common. All squints should be seen by an eye mental factors must be important for some
specialist as soon as possible. Some squints can stammerers. There are relatively large numbers
be corrected by exercises or spectacles; others of stammerers in highly competitive societies,
require surgery. where status and prestige are important and
high standards of speech competence are
SSRIs valued.
See SELECTIVE SEROTONIN-REUPTAKE INHIBI- Different treatments have been demon-
S TORS (SSRIS). strated to produce considerable benefit, their
basic outline being similar. A long period of
Stabs time is spent in training stammerers to speak
See WOUNDS. in a different way (fluency-shaping tech-
niques). This may include slowing down the
Staghorn Calculus rate of speech, gentle onset of utterance, con-
A branched renal stone formed in the image of tinuous flow with correct juncturing, etc.
the collecting system of the kidney (see KID- When the targets have been achieved within
NEYS). It fills the calyces and pelvis and is com- the clinic, a series of planned speech assign-
monly associated with an infection of the urine, ments outside the clinic is undertaken. In
particularly Proteus vulgaris. The calculus may these assignments, and initially in everyday
lead to pyonephrosis and an ABSCESS of the situations, the fluency-enchancing techniques
kidney. have to be used conscientiously. Gradually
speech is shaped towards normality requiring
Stammering less and less effort. Therapy may also include
A disruption of the forward flow of speech. The some work on attitude change (i.e. helping the
individual knows what he or she wants to say, client to see him or herself as a fluent speaker)
 Statins 671

and possibly general communicative skills ous enzymes (see ENZYME) such as the PTYALIN
training. of the SALIVA. Starch forms a chief constituent
For information about organisations con- of the carbohydrate foods (see DIET); and in the
cerned with stammering, see Appendix 2. process of digestion, the above-mentioned
change takes place to prepare it for absorption.
Standard Deviation It is also slowly broken down in the process of
A statistical measure of the spread of observa- cooking.
tions about their arithmetic mean. It is a meas- Starch is used as a constituent of dusting
ure regularly used in working out the results of powders for application to chafed or irritable
trials about clinical treatment. areas of the skin.

Stannosis Starvation
The form of PNEUMOCONIOSIS caused by the A condition that results from a lack of food for
inhalation of stannous (tin) oxide, which occurs a long time. The person suffers weight loss and
in tin-ore mining. changes in the bodys METABOLISM, with pro-
duction of potentially harmful chemicals called
Stanozolol ketones (see KETONE) and ACETONE. Sometimes
See ANABOLIC STEROIDS. starvation may occur as a result of an eating
disorder (see EATING DISORDERS Anorexia
Stapedectomy nervosa). In cases of slow starvation, the vitality
An operation on the middle EAR to remove the of the tissues is reduced and they become more
STAPES and replace it with an artificial alterna- liable to tuberculosis and other diseases. (See also
tive. The procedure is aimed at treating DEAF- FASTING.)
NESS caused by otosclerosis in which the stapes
becomes fixed by an overgrowth of bone, pre- Stasis
venting it from transmitting sound. Stapedec- A term applied to stoppage of the flow of blood
tomy improves hearing in around 90 per cent of in the vessels or of the food materials down the
those people who have the operation. (See EAR, intestinal canal.
DISEASES OF.)
STAT
Stapes An abbreviation (for statim) meaning straight-
The innermost of the small trio of bones in the away usually applying to a request by a doctor
middle EAR. It is stirrup-shaped, articulates for a drug to be given without delay.
with the incus, and is linked to the oval window
of the inner ear. Statins
A group of LIPID-lowering drugs used to treat
Staphylococcus primary hypercholesterolaemia a condition in
Staphylococcus is a genus of gram-positive bac- which the concentrations of LIPOPROTEINS in
terium (see GRAMS STAIN; BACTERIA) which the blood plasma are raised, increasing the like-
under the microscope appears in small masses lihood of affected individuals developing cor-
like bunches of grapes. It is one of the most onary heart disease. Statins act by competitively
common infectious micro-organisms and is inhibiting an ENZYME called 3-hydroxy-3- S
found, for example, in the PUS discharged from methylglutaryl coenzyme A (HMG CoA)
BOILS (FURUNCULOSIS). (See also reductase. This enzyme plays a part in the syn-
MICROBIOLOGY.) thesis of CHOLESTEROL, particularly in the
LIVER. Statins are more effective than other
Starch classes of drugs in lowering body concentra-
A substance belonging to that group of carbo- tions of LDL-cholesterol but less effective than
hydrate known as the amyloses. It is the form in fibrates in reducing triglyceride concentration.
which utilisable CARBOHYDRATE is stored in Their use results in significant reductions in
granules within the seeds and roots of many heart attacks (myocardial infarctions) and other
plants. adverse cardiovascular events, such as STROKE.
Starch is converted into sugar when treated Recent research shows that drugs which reduce
with heat in presence of a dilute acid. It is lipid concentrations may prevent as many as
changed largely into dextrin when exposed to a one-third of myocardial infarctions and deaths
considerable degree of dry heat, as in toasting from coronary disease. Statins are valuable in
bread; and a similar change into dextrin and preventing coronary events in patients at
malt-sugar takes place under the action of vari- increased risk of those conditions. They should
 672 Status Asthmaticus

be used in conjunction with other preventive cells that develop naturally in the body. UK
measures such as low-fat diets, reduction in government legislation constrains the use of
alcohol consumption, taking exercise and stop- human embryos in research (see ETHICS) and
ping smoking. Among statin drugs available are the ethical aspects of taking this stem-cell cul-
atorvastatin, cerivastatin sodium, fluvastatin, ture technique forwards will have to be
pracastatin sodium and simvasatin. (See HEART, resolved. Nevertheless, this discovery points the
DISEASES OF; HYPERLIPIDAEMIA.) biological way to the use of genetic engineering
in selecting differentiated specialised cells from
Status Asthmaticus which replacement tissues could be grown for
Repeated attacks of ASTHMA, with no respite use as transplants to rectify absent or damaged
between the spasms, usually lasting for more tissues in the human body.
than 24 hours. The patient is seriously dis- Research into potential use of stem cells has
tressed and, untreated, the condition may lead raised expectations that in the long term they
to death from respiratory failure and exhaus- may prove to be an effective regenerative treat-
tion. Continuous or very frequent use of ment for a wide range of disorders including
nebulised bronchodilators, intravenous cortico- PARKINSONISM, ALZHEIMERS DISEASE, type-2
steroid treatment, and other skilled medical diabetes (see under DIABETES MELLITUS), myo-
care are urgently required. cardial infarction (see HEART, DISEASES OF),
severe burns, osteoporosis (see under BONE, DIS-
Status Epilepticus ORDERS OF) and the regeneration of blood to
Repeated epileptic fits (see EPILEPSY) with no replace the need for BONE MARROW TRANS-
return to consciousness between them. Breath- PLANT. Recent research has shown that adult
ing stops between each fit and the body is stem cells may also be stimulated to produce
deprived of oxygen which causes damage to the new cell lines. If successful, this would elimin-
brain. Urgent medical attention is required to ate the need to use embryos and thus resolve
control the condition, or the patient may suffer existing ethical dilemmas over the use of stem
permanent brain damage. cells.

STD(s) Stenosis
See SEXUALLY TRANSMITTED DISEASES (STDS). An unnatural narrowing in any passage or ori-
fice of the body. The word is especially used in
Steatoma connection with the four openings of the
A fatty, cystic tumour. HEART at which the valves are situated. (See
HEART, DISEASES OF.)
Steatorrhoea
Any condition characterised by the passing of Stent
stools (FAECES) containing an excess of FAT. (See A surgical device used to assist the healing of an
MALABSORPTION SYNDROME.) operative anastamosis a joining-up of two
structures. A splint is left inside the lumen of a
Stem Cell duct and this drains the contents.
Stem CELLS develop a few days after an egg
S (ovum) is fertilised by a spermatozoon and Stereognosis
starts developing to form an EMBRYO. These The faculty of recognising the solidity of
master cells are crucial to the development of a objects, and thus their nature, by handling
normal embryo. They contain a specialised them.
ENZYME that gives them the facility to divide
indefinitely, developing into the many different Stereotaxis
specialised cells that comprise the various tis- The procedure using computer-controlled X-
sues in the body for example, skin, blood, ray images whereby precise localisation in space
muscle, glands or nerves. is achieved. It is applied to that branch of sur-
In a highly significant advance in research, a gery known as stereotactic neurosurgery, in
scientific team in the United States obtained which the surgeon is able to localise precisely
stem cells from newly formed human embryos those areas of the brain on which he or she
donated by women who had become preg- wishes to operate.
nant after successful in vitro fertilisation and
successfully cultivated these cells in the labora- Sterilisation
tory. This achievement opened the way to repli- Sterilisation means either (1) the process of
cating in the laboratory, the various specialised rendering various objects such as those which
 Stigma 673

come in contact with wounds, and various Steroid

foods free from microbes, or (2) the process of The group name for compounds that resemble
rendering a person incapable of producing CHOLESTEROL chemically. The group includes
children. the sex hormones, the hormones of the adrenal
The manner of sterilising bedding, furniture, cortex, and bile acids. They have a powerful
and the like, after contact with a case of infec- influence on the normal functioning of the
tious disease, is given under DISINFECTION; body, and natural and synthetic steroids are
whilst the sterilisation of instruments, dress- used in the treatment of many disorders. (See
ings, and skin surfaces, necessary before surgical CORTICOSTEROIDS; ENDOCRINE GLANDS.)
procedures, is mentioned in the same article
and also under ANTISEPTICS, ASEPSIS, and Stertor
WOUNDS. For general purposes, one of the Stertor is a form of noisy breathing, similar to
cheapest and most effective agents is boiling SNORING, and usually due to flapping of the
water or steam. soft PALATE. Whereas ordinary snoring results
from sleeping with the mouth open, stertor is
Bacteriological sterilisation may be the result of paralysis of the soft palate: this may
effected in many ways, and different methods be the result of a stroke, suffocation, concus-
are used in different cases. sion, drunkenness, or poisoning by OPIUM or
chloroform. In severe cases of paralysis, the
Reproductive sterilisation In women, tongue may loll back against the back of the
this is performed by ligating (cutting) and then throat, resulting in a very loud sound. In such
tying the FALLOPIAN TUBES the tubes that cases breathing may be rapidly relieved by pull-
carry the OVUM from the ovary (see OVARIES) to ing the lower jaw forwards, pulling the tongue
the UTERUS. Alternatively, the tubes may be out of the mouth, or turning the person on to
sealed-off by means of plastic and silicone clips one side.
or rings. The technique is usually performed
(by LAPAROSCOPY) through a small incision, or Stethoscope
cut, in the lower abdominal wall. It has no An instrument used for listening to the sounds
effect on sexual or menstrual function, and, produced by the action of the lungs, heart, and
unlike the comparable operation in men, it is other internal organs. (See AUSCULTATION.)
immediately effective. The sterilisation is usu-
ally permanent (around 005 pregnancies occur Stevens-Johnson Syndrome
for every 100 women years of use), but See ERYTHEMA Erythema multiforme.
occasionally the two cut ends of the Fallopian
tubes reunite, and pregnancy is then again pos- Stiffness
sible. Removal of the uterus and/or the ovaries A condition which may be due to a change in
also sterilises a woman but such procedures are the joints, ligaments, tendons, or muscles, or to
only used when there is some special reason, the influence of the nervous system over the
such as the presence of a tumour. muscles of the part affected. Stiffness is associ-
The operation for sterilising men is known as ated with various forms of arthritis or muscular
VASECTOMY. disorders and with the effects of injuries to
joints, tendons and muscles. Stiffness of the S
Sterility neck muscles resulting in bending the head
The state of (1) being free of infectious agents backwards, and of the hamstring muscles, caus-
or (2) permanent INFERTILITY. ing difficulty in straightening the lower limbs, is
a sign of MENINGITIS. Stiffness or spasticity also
Sternum occurs in certain diseases of the central nervous
The scientific name for the breastbone. This is a system.
long, flat, bony plate that comprises the central
part of the chest. Made up of three parts: an Treatment is of the underlying disease or
upper triangular piece (manubrium); a middle injury. Mild stiffness can be treated symptom-
part (the body); and at the bottom end the atically with local warmth and ANALGESICS.
small, flexible xiphoid process. The two clav- PHYSIOTHERAPY is helpful in relieving stiffness
icles articulate to the manubrium. Seven pairs as a result of muscle or joint injuries.
of costal cartilages link the sternum to the ribs.
The sternum is very strong and a powerful blow Stigma
is needed to fracture it: such an injury may Any spot or impression upon the SKIN. The
damage the underlying heart and lungs. term, stigmas of degeneration, is applied to
 674 Stilboestrol

physical defects that are found in people with ORDERS OF) following unusually hard exertion,
learning disabilities (see LEARNING DISABILITY). but care must be taken that this trivial condi-
tion is not taken for PLEURISY or for a fractured
Stilboestrol rib. The word is also used to mean the repair of
A synthetic oestrogen (see OESTROGENS). Its skin following surgery or any other trauma.
physiological actions are closely similar to those
of the natural ovarian hormone, and it has the St Johns Wort
great merit of being active when taken by A herbal remedy which has achieved popularity
mouth. The drug may help patients suffering as a treatment for mild depression. It may, how-
from cancer of the PROSTATE GLAND, inducing ever, induce the production of enzymes (see
in some cases regression of the primary tumour ENZYME) that metabolise drugs, and several
and of secondary deposits in bone. important interactions have been identified
which may result in unwanted side-effects, even
Stilboestrol Diphosphate when treatment with St Johns Wort is stopped.
See OESTROGENS.
Stokes-Adams Syndrome
Stilet A term applied to a condition in which slow-
A stilet, or stilette, is the delicate probe or the ness of the PULSE is associated with attacks of
wire used to clear a catheter (see CATHETERS) or unconsciousness, and which is due to
ARRHYTHMIA of the cardiac muscle or even
hollow needle.
complete heart block. Usually the heart returns
to normal rhythm after a short period, but
Stillbirth patients who suffer from the condition are
A stillborn child is any child which has issued
commonly provided with a PACEMAKER to
forth from its mother after the 24th week of
maintain normal cardiac function (see also
pregnancy and which did not at any time after
CARDIAC PACEMAKER).
being completely expelled from its mother,
breathe or show any other sign of life. In the
United Kingdom in 2002 the number of still-
Stoma
A stoma refers to an opening constructed when
births and deaths at under one week of age
the bowel has to be brought to the skin surface
(PERINATAL MORTALITY) was 5.6 per 1,000 live
to convey gastrointestinal contents to the exter-
births.
ior. It is derived from the Greek word meaning
mouth. In the United Kingdom there are about
Stills Disease 100,000 patients with a COLOSTOMY, 10,000
Or juvenile rheumatoid arthritis see JUVENILE with an ILEOSTOMY and some 2,000 with a
IDIOPATHIC ARTHRITIS (JIA).
urostomy, in which the ureters (see URETER) are
brought to the skin surface. They may be
Stimulant undertaken because of malignancy of the colon
A drug or other agent that prompts the activity or rectum (see INTESTINE) or as a result of
of a body system or function. For example, the inflammatory bowel diseases such as CROHNS
sight and smell of food stimulates salivation, DISEASE. Urostomies usually take the form of an
S and the rods and cones in the retina of the eye isolated loop of ilium into which the ureters
are stimulated by light. Another example is the have been implanted and which in its turn is
use of amphetamines and caffeine to stimulate either brought to the skins surface or converted
the central nervous system and make an indi- into an artificial bladder. This is undertaken
vidual more alert and active or, if taken in because of bladder cancer or because of neuro-
excess, hyperactive. In treatment procedures, logical diseases of the bladder. The stomas drain
electrical stimulation may be used to bring into appliances such as disposable plastic bags.
muscles into action. Aromatics, spices and bit- Most of the modern appliances collect the
ters are traditional stimulants of digestive effluent of the stoma without any leak or odour.
processes. Patients with stomas often find explanatory
booklets helpful: Living with your Colostomy
Stings and Understanding Colostomy are examples.
See BITES AND STINGS. They are published by the British Colostomy
Association.
Stitch
A popular name for a sharp pain in the side. It Stomach
is generally due to cramp (see MUSCLES, DIS- This is a distensible, sac-like organ with an
 Stomach, Diseases of 675

average adult capacity of 15 litres situated in ilise the food; pepsin, a digestive ENZYME in the
the upper abdomen. It is positioned between gastric juices, breaks down the protein in food.
the OESOPHAGUS and DUODENUM, lying just The juices also contain intrinsic factor, vital for
beneath the DIAPHRAGM to the right of the the absorption of vitamin B12 when the chyle
SPLEEN and partly under the LIVER. The stom- as the stomach contents are called reaches the
ach is a part of the gastrointestinal tract with its intestine. This chyle is of creamy consistency
walls formed of layers of longitudinal and circu- and is the end product of enzymic action and
lar muscles and lined by glandular cells that rhythmic contractions of the stomachs muscles
secrete gastric juice. It is well supplied with every 30 seconds or so. Food remains in the
blood vessels as well as nerves from the auto- stomach for varying lengths of time depending
nomic system which enter via the phrenic upon its quantity and nature. At regular inter-
nerve. The exit of the stomach is guarded by a vals a bolus of chyle is forced into the duo-
ring of muscle called the pyloric sphincter denum by contractions of the stomach muscles
which controls the passage of food into the coordinated with relaxation of the pyloric
duodenum. sphincter.

Function As well as the stomachs prime role Stomach, Diseases of

in physically and physiologically breaking down Gastritis is the description for several unrelated
the food delivered via the oesophagus, it also diseases of the gastric mucosa.
acts as a storage organ a function that enables
people to eat three or four times a day instead of Acute gastritis is an inflammatory reaction
every 30 minutes or so as their metabolic needs of the gastric mucosa to various precipitating
would otherwise demand. Gastric secretion is factors, ranging from physical and chemical
stimulated by the sight and smell of food and its injury to infections. Acute gastritis (especially of
subsequent arrival in the stomach. The secre- the antral mucosas) may well represent a reac-
tions, which contain mucus and hydrochloric tion to infection by a bacterium called Helico-
acid (the latter produced by parietal cells), ster- bacter pylori. The inflammatory changes usually

Interior of stomach.
 676 Stomach, Diseases of

go after appropriate antibiotic treatment for the much greater than for patients with duodenal
H. pylori infection. ulcer who have not had surgery.
Acute and chronic inflammation occurs in
response to chemical damage of the gastric Stress gastritis Acute stress gastritis
mucosa. For example, REFLUX of duodenal con- develops, sometimes within hours, in indi-
tents may predispose to inflammatory acute viduals who have undergone severe physical
and chronic gastritis. Similarly, multiple small trauma, BURNS (Curling ulcers), severe SEPSIS or
erosions or single or multiple ulcers have major diseases such as heart attacks, strokes,
resulted from consumption of chemicals, espe- intracranial trauma or operations (Cushings
cialy aspirin and antirheumatic NON- ulcers). The disorder presents with multiple
STEROIDAL ANTI-INFLAMMATORY DRUGS superficial erosions or ulcers of the gastric
(NSAIDS). mucosa, with HAEMATEMESIS and MELAENA
Acute gastritis may cause anorexia, nausea, and sometimes with perforation when the acute
upper abdominal pain and, if erosive, haemor- ulcers erode through the stomach wall. Treat-
rhage. Treatment involves removal of the ment involves inhibition of gastric secretion
offending cause. with intravenous infusion of an H2-receptor-
antagonist drug such as RANITIDINE or FAMO-
Chronic gastritis Accumulation of cells TIDINE, so that the gastric contents remain at a
called round cells in the gastric mucosal charac- near neutral pH. Despite treatment, a few
terises chronic gastritis. Most patients with patients continue to bleed and may then require
chronic gastritis have no symptoms, and treat- radical gastric surgery.
ment of H. pylori infection usually cures the
condition. Gastric ulcer Gastric ulcers were common
in young women during the 19th century,
Atrophic gastritis A few patients with markedly fell in frequency in many western
chronic gastritis may develop atrophic gastritis. countries during the first half of the 20th cen-
With or without inflammatory change, this tury, but remained common in coastal northern
disorder is common in western countries. The Norway, Japan, in young Australian women,
incidence increases with age, and more than 50 and in some Andean populations. During the
per cent of people over 50 may have it. A more latter half of this century, gastric ulcers have
complete and uniform type of ATROPHY, called again become more frequent in the West, with a
gastric atrophy, characterises a familial disease peak incidence between 55 and 65 years.
called PERNICIOUS ANAEMIA. The cause of the The cause is not known. The two factors
latter disease is not known but it may be an most strongly associated with the development
autoimmune disorder. of duodenal ulcers gastric-acid production
Since atrophy of the corpus mucosa results in and gastric infection with H. pylori bacteria
loss of acid- and pepsin-secreting cells, gastric are not nearly as strongly associated with gastric
secretion is reduced or absent. Patients with ulcers. The latter occur with increased fre-
pernicious anaemia or severe atrophic gastritis quency in individuals who take aspirin or
of the corpus mucosa may secrete too little NSAIDs. In healthy individuals who take
intrinsic factor for absorption of vitamin B12 NSAIDs, as many as 6 per cent develop a gas-
S and so can develop severe neurological disease tric ulcer during the first week of treatment,
(subacute combined degeneration of the spinal while in patients with rheumatoid arthritis who
cord). are being treated long term with drugs, gastric
Patients with atrophic gastritis often have ulcers occur in 2040 per cent. The cause is
bacterial colonisation of the upper alimentary inhibition of the enzyme cyclo-oxygenase,
tract, with increased concentration of nitrite which in turn inhibits the production of repair-
and carcinogenic N-nitroso compounds. These, promoting PROSTAGLANDINS.
coupled with excess growth of mucosal cells, Gastric ulcers occur especially on the lesser
may be linked to cancer. In chronic corpus gas- curve of the stomach. The ulcers may erode
tritis, the risk of gastric cancer is about 34 through the whole thickness of the gastric wall,
times that of the general population. perforating into the peritoneal cavity or pene-
trating into liver, pancreas or colon.
Postgastrectomy mucosa The mucosa Gastric ulcers usually present with a history
of the gastric remnant after surgical removal of of epigastric pain of less than one year. The pain
the distal part of the stomach is usually tends to be associated with anorexia and may be
inflamed and atrophic, and is also premalig- aggravated by food, although patients with
nant, with the risk of gastric cancer being very prepyloric ulcers may obtain relief from eating
 Strabismus 677

or taking antacid preparations. Patients with pernicious anaemia, postgastrectomy mucosa,

gastric ulcers also complain of nausea and and atrophic gastritis (see above). Around 90 per
vomiting, and lose weight. cent of gastric cancers have the microscopic
The principal complications of gastric ulcer appearance of abnormal mucosal cells (and are
are haemorrhage from arterial erosion, or per- called adenocarcinomas). Most of the
foration into the peritoneal cavity resulting in remainder look like endocrine cells of lymphoid
PERITONITIS, abscess or fistula. tissue, although tumours with mixed micro-
Aproximately one in two gastric ulcers heal scopic appearance are common.
spontaneously in 23 months; however, up to Early gastric cancer may be symptomless
80 per cent of the patients relapse within 12 and, in countries like Japan with a high fre-
months. Repeated recurrence and rehealing quency of the disease, is often diagnosed during
results in scar tissue around the ulcer; this may routine screening of the population. In more
cause a circumferential narrowing a condition advanced cancers, upper abdominal pain, loss
called hour-glass stomach. of appetite and loss of weight occur. Many
The diagnosis of gastric ulcer is confirmed by present with obstructive symptoms, such as
ENDOSCOPY. All patients with gastric ulcers vomiting (when the pylorus is obstructed) or
should have multiple biopsies (see BIOPSY) to difficulty with swallowing. METASTASIS is obvi-
exclude the presence of malignant cells. Even ous in up to two-thirds of patients and its pres-
after healing, gastric ulcers should be endo- ence contraindicates surgical cure. The diag-
scopically monitored for a year. nosis is made by endoscopic examination of the
Treatment of gastric ulcers is relatively sim- stomach and biopsy of abnormal-looking areas
ple: a course of one of the H2 RECEPTOR ANT- of mucosa. Treatment is surgical, often with
AGONISTS heals gastric ulcers in 3 months. In additional chemotherapy and radiotherapy.
patients who relapse, long-term indefinite
treatment with an H2 receptor antagonist such Stomach Tube
as ranitidine may be necessary since the ulcers A soft rubber or plastic tube with rounded end,
tend to recur. Recently it has been claimed that and usually about 75 cm (30 inches) in length,
gastric ulcers can be healed with a combination which is used for washing out the stomach
of a bismuth salt or a gastric secretory inhibitor when it contains some poisonous material. (See
for example, one of the PROTON PUMP GASTRIC LAVAGE.) A narrower tube, 90 cm (36
INHIBITORS such as omeprazole or lansoprazole inches) in length, is used to obtain a sample of
together with two antibiotics such as AMOXY- gastric juice for examination. Such a tube can
CILLIN and METRONIDAZOLE. The long-term also be allowed to pass out of the stomach into
outcome of such treatment is not known. Par- the duodenum so that the contents of the upper
tial gastrectomy, which used to be a regular part of the small intestine are similarly obtained
treatment for gastric ulcers, is now much more for analysis.
rarely done unless the ulcer(s) contain pre-
cancerous cells. Stomach Washout
See GASTRIC LAVAGE.
Cancer of the stomach Cancer of the
stomach is common and dangerous and, Stomatitis
worldwide, accounts for approximately one in Inflammation or ulceration of the mouth. (See S
six of all deaths from cancer. There are marked MOUTH, DISEASES OF.)
geographical differences in frequency, with a
very high incidence in Japan and low incidence -Stomy
in the USA. In the United Kingdom around 33 A suffix signifying formation of an opening in
cases per 100,000 population are diagnosed an organ by operation: for example,
annually. Studies have shown that environ- COLOSTOMY.
mental factors, rather than hereditary ones, are
mainly responsible for the development of gas- Stone
tric cancer. Diet, including highly salted, See URINARY BLADDER, DISEASES OF; GALL-
pickled and smoked foods, and high concentra- BLADDER, DISEASES OF.
tions of nitrate in food and drinking water, may
well be responsible for the environmental Stools
effects. See FAECES.
Most gastric ulcers arise in abnormal gastric
mucosa. The three mucosal disorders which Strabismus
especially predispose to gastric cancer include See SQUINT.
 678 Strain

Strain and symptoms range from minor discomfort

Stretching or tearing of muscle fibres caused by to sore throat, fever, general malaise and
subjecting them to sudden pulling. Bleeding enlarged LYMPH nodes in the neck. If symp-
into the muscle causes pain and swelling and toms are severe the infection may lead to
sometimes muscle spasm. Application of ice SCARLET FEVER. PENICILLIN is the treatment of
packs and strapping, coupled with a day or choice.
twos rest and analgesics, are usually sufficient
to remedy most strains. Sometimes anti- Streptococcus
inflammatory drugs or physiotherapy may be Streptococcus is a variety of gram-positive bac-
required. terium (see GRAMS STAIN; BACTERIA) which
under the microscope has much the appearance
Strangulation of a string of beads. Most species are sapro-
The constriction of a passage or tube in the phytic (see SAPROPHYTE); a few are PATHOGENIC
body that blocks the blood flow and disturbs and these include haemolytic types which can
the working of the affected organ. It is usually destroy red blood cells in a culture of blood
caused by compression or twisting. Strangula- agar. This offers a method of classifying the
tion customarily occurs when part of the varying streptococcal strains. Alpha-
INTESTINE herniates either inside the abdomen haeomolytic streptococci are usually associated
or outside as in an inguinal HERNIA. If a section with bacterial ENDOCARDITIS. SCARLET FEVER
of the intestine twists, this may strangulate and is caused by a -haeomolytic streptococcus
is known as a VOLVULUS. called S. pyogenes. S. pneumoniae, also called
Strangulation of a persons neck, either with PNEUMOCOCCUS, causes respiratory-tract infec-
a ligature or with the hands, obstructs the jugu- tions, including PNEUMONIA. S. pyogenes may
lar veins in the neck, preventing the normal on its own, or with other bacteria, cause severe
outflow of blood from the brain and head. The NECROTISING FASCIITIS or CELLULITIS in which
TRACHEA is also compressed, cutting off the oedema and death of subcutaneous tissues
supply of air to the lungs. The combination of occur. The infection can spread very rapidly
these effects leads to HYPOXIA and damage to and, unless urgently treated with ANTIBIOTICS
the brain. If not quickly relieved, unconscious- and sometimes surgery, death may quickly
ness and death follow. Strangulation may be result. This spread is related to the ability of S.
deliberate or accidental the latter being a par- pyogenes to produce toxic substances called exo-
ticular hazard for children, for example, when toxins. Although drug-resistant forms are
playing with a rope. Removal of the constric- occurring, streptococcal infections usually
tion, artificial respiration, and medical atten- respond to treatment with antibiotics.
tion are urgently necessary.
Streptokinase
Strangury An ENZYME produced by certain streptococci
A condition in which there is constant desire to (see STREPTOCOCCUS). It acts as a PLASMINO-
pass water, accompanied by a straining sensa- GEN activator, and hence enhances FIBRINOLY-
tion, though only a few drops can be voided. It SIS. The most important use of streptokinase is
is a symptom of inflammation in the urinary in the treatment of myocardial infarction (see
S tract. HEART, DISEASES OF) in the first 12 hours after
the initial diagnosis. Subsequently, use of this
Strapping thrombolytic drug should be under hospital
The application of strips of adhesive plaster, supervision. It is given intravenously, in hos-
one overlapping the other, so as to cover and pital by infusion. It may be given as an infusion
exert pressure on an area of the body. This to treat severe THROMBOSIS or EMBOLISM, par-
treatment is used in cases of injury or disease ticularly when they occur in a limb, and in deep
when it is desired to keep a part at rest: for venous thrombosis. Being antigenic and very
example, strapping may be applied to the chest expensive it is rarely used for more than two
in cases of pleurisy and fracture of the ribs. days, and is followed by anticoagulation ther-
Also, it is often used to prevent the movement apy. The chief risk is haemorrhage, so an antifi-
of joints which are sprained or otherwise brinolytic such as aminocaproic acid should
injured. always be available.

Strep Throat Streptomycin

An infection of the throat with STREPTOCOC- Streptomycin is an antibacterial substance
CUS bacteria: it is most common in children obtained from the soil mould, Streptomyces
 Stroke 679

griseus, first isolated in 1944 and the first training. The main initial feature is pain over
antibiotic to be effective against the tubercle the affected bone that has been subjected to
bacillus. It was once routinely used to treat abnormal physical stress. This is usually insidi-
TUBERCULOSIS; because of side-effects and the ous in onset, and worse at night and during and
development of other drugs, it is now rarely after exercise. It is accompanied by tenderness,
used except for in cases of resistant tuberculosis. and a lump may be felt over the affected site. X-
One of the AMINOGLYCOSIDES, streptomycin ray evidence only appears after several weeks.
has two disadvantages. The most important of Treatment consists of rest, some form of
these is the tendency of organisms to become external support, and in the initial stage
resistant to it. This means that the administra- ANALGESICS to deaden or kill the pain. (See also
tion of this antibiotic must be carefully super- BONE, DISORDERS OF Bone fractures.)
vised to ensure that correct dosage is being
used. The other disadvantage is that strepto- Striae
mycin produces toxic effects, especially disturb- Stretch-marks seen in the skin, common in ado-
ance of the vestibular and hearing apparatus. lescent boys and girls owing to stretching of the
This may result in DEAFNESS, VERTIGO, and skin by rapid growth (striae distensae). In boys,
TINNITUS. Whilst in many cases these toxic striae occur around the shoulders and thighs; in
manifestations disappear when the antibiotic is girls the breasts and hips are affected. In both
withdrawn, they may be permanent. For this sexes horizontal striae on the back may be mis-
reason therefore streptomycin must always be taken for signs of trauma. Striae are common in
used with special care. women in late pregnancy, especially on the
lower abdomen (striae gravidarum). Injudicious
Stress prolonged use of potent topical CORTICO-
Any factor or event that threatens a persons STEROIDS can induce striae, particularly about
health or adversely affects his or her normal the groins, inner thighs or armpits. Prolonged
functioning. Injury, disease or worry are com- high-dose oral STEROID therapy may cause
mon examples; others include internal con- widespread striae.
flicts, emotive life events such as the death of
a close relative or friend, the birth of a baby, Stricture
separation or divorce pressures at work or a A narrowing in any of the natural passages of
hostile environment such as war or famine. the body, such as the GULLET, the bowel, or the
Some individuals seem to be more prone than URETHRA. It may be due to the development of
others to develop medical problems related to some growth in the wall of the passage affected,
stress. or to pressure upon it by such a growth in some
Stress prompts the body to raise its output of neighbouring organ, but in the majority of
HORMONES such as ADRENALINE and CORTI- cases a stricture is the result of previous ulcer-
SOL, causing changes in blood pressure, heart ation on the inner surface of the passage,
rate and metabolism. These are physiological followed by contraction of the scar. (See INTES-
responses intended to improve a persons phys- TINE, DISEASES OF; URETHRA, DISEASES OF.)
ical and mental performance the fight or
flight reaction to fear. Stress may, however, dis- Stridor
rupt the ability to cope. Constant or recurrent A noise associated with inspiration due to nar- S
exposure to stress may produce symptoms such rowing of the upper airway, in particular the
as anxiety, depression, headaches, indigestion, LARYNX.
diarrhoea, palpitations and general malaise (see
POST-TRAUMATIC STRESS DISORDER (PTSD)). Stroke
Treatment can be difficult and prolonged; Stroke, or cerebrovascular accident (CVA), is
counselling can help as can ANXIOLYTICS or sudden damage to BRAIN tissue caused either by
ANTIDEPRESSANT DRUGS but a change in job a lack of blood supply or rupture of a blood
or lifestyle may be necessary in some vessel (see ISCHAEMIC STROKE). The affected
circumstances. brain cells die and the parts of the body they
control or receive sensory messages from cease
Stress Fractures to function.
Stress fractures are comparatively common in
sportspeople. They tend to occur when an Causes Blood supply to the brain may be
undue amount of exercise is taken that is, an interrupted by arteries furring up with ATH-
amount of exercise which an individual is not EROSCLEROSIS (which is accelerated by HYPER-
capable of coping with in his or her state of TENSION and DIABETES MELLITUS, both of
 680 Stroma

which are associated with a higher incidence of small doses of aspirin stop platelets clumping
strokes) or being occluded by blood clots aris- together to form plugs in blood vessels. Both
ing from distant organs such as infected heart treatments reduce the likelihood of minor tran-
valves or larger clots in the heart (see BLOOD sient ischaemic episodes proceeding to a major
CLOT; THROMBOSIS). Hearts with an irregular stroke.
rhythm are especially prone to develop clots. Once the latter has occurred, there is no
Patients with thick or viscous blood, clotting effective treatment to reduce the damage to
disorders or those with inflamed arteries for brain tissue. Function will return to the affected
example, in SYSTEMIC LUPUS ERYTHEMATOSUS part of the body only if and when the brain
(SLE) are particularly in danger of having recovers and messages are again sent down the
strokes. Bleeding into the brain arises from appropriate nerves. Simple movements are
areas of weakened blood vessels, many of which more likely to recover than delicate ones, and
may be congenital. sophisticated functions have the worst outlook.
Thus, movement of the thigh may improve
Symptoms Minor episodes due to temporary more easily than fine movements of fingers, and
lack of blood supply and oxygen (called TRAN- any speech impairment is more likely to be
SIENT ISCHAEMIC ATTACKS OR EPISODES (TIA, permanent. A rehabilitation team can help to
TIE)) are manifested by short-lived weakness or compensate for any disabilities the subject may
numbness in an arm or leg and may precede a have. Physiotherapists maintain muscle tone
major stroke. Strokes cause sudden weakness or and joint flexibility, whilst waiting for power to
complete paralysis of the muscles controlled by return; occupational therapists advise about
the part of the brain affected, as well as sensory functional problems and supply equipment to
changes (e.g. numbness or tingling). In the help patients overcome their disabilities; and
worst cases these symptoms and signs may be speech therapists help with difficulties in swal-
accompanied by loss of consciousness. If the lowing, improve the clarity of remaining speech
stroke affects the area of the brain controlling or offer alternative methods of communication.
the larynx and throat, the patient may suffer District nurses or home helps can provide sup-
slurring or loss of speech with difficulty in initi- port to those caring for victims of stroke at
ating swallowing. When the face is involved, home. Advice about strokes may be obtained
the mouth may droop and the patient dribble. from the Stroke Association.
Strokes caused by haemorrhage may be pre-
ceded by headaches. Rarely, CVAs are compli- Stroma
cated by epileptic fits (see EPILEPSY). If, on the The name applied to the tissue which forms the
other hand, numerous small clots develop in framework and covering of an organ.
the brain rather than one major event, this may
manifest itself as a gradual deterioration in Strongyloidiasis
the patients mental function, leading to This infection is caused by nematode worms of
DEMENTIA. the genus Strongyloides spp. the great majority
being from S. stercoralis. This helminth is pres-
Investigations Tests on the heart or COM- ent throughout most tropical and subtropical
PUTED TOMOGRAPHY or ultrasonic scans (see countries; a single case report has been made in
S ULTRASOUND) on arteries in the neck may indi- England about an individual who had not
cate the original sites of distantly arising clots. been exposed to such an environment. Larvae
Blood tests may show increased thickness or usually penetrate intact skin, especially the feet
tendency to clotting, and the diagnosis of gen- (as with hookworm infection). Unlike hook-
eral medical conditions can explain the pres- worm infection, eggs mature and hatch in the
ence of inflamed arteries which are prone to lower gastrointestinal tract; thus larvae can
block. Special brain X-rays show the position immediately re-enter the circulation in the
and size of the damaged brain tissue and can colo-rectum or perianal region, setting up an
usually distinguish between a clot or infarct and auto-infection cycle. Therefore, infection can
a rupture of and haemorrhage from a blood ves- continue for the remaining lifespan of the
sel in the brain. individual. Severe malnutrition may be a pre-
disposing factor to infection, as was the case
Management It is better to prevent a stroke in prisoners of war in south-east Asia during
than try to cure it. The control of a persons World War II.
diabetes or high blood pressure will reduce the Whilst an infected patient is frequently
risk of a stroke. Treatment with ANTICOAGU- asymptomatic, heavy infection can cause jeju-
LANTS prevents the formation of clots; regular nal mucosal abnormalities, and an absorptive
 Subarachnoid Haemorrhage 681

defect, with weight loss. During the migratory St Vituss Dance

phase an itchy linear rash (larva currens) may be An obsolete name for CHOREA.
present on the lower abdomen, buttocks, and
groins; this gives rise to recurrent transient itch- Stye
ing. In an immunosuppressed individual, the See under EYE, DISORDERS OF.
hyperinfection syndrome may ensue; migra-
tory larvae invade all organs and tissues, includ- Styptics
ing the lungs and brain. Associated with this Applications which check bleeding, either by
widespread infection, the patient may develop making the blood vessels contract more firmly
an Enterobacteriacae spp. SEPTICAEMIA; this, or by causing rapid clotting in the blood (see
together with S. stercoralis larvae, produces a COAGULATION). Some possess both modes of
MENINGOENCEPHALITIS. There is no evidence
action.
that this syndrome is more common in patients
with HIV infection. Sub-
Diagnosis consists of visualisation of S. Prefix signifying under, near, or moderately.
stercoralis (larvae or adults) in a jejunal biopsy-
section or aspirate. Larvae may also be demon-
strable in a faecal sample, especially following
Subacute
The description applied to a disease the dur-
culture. Eosinophilia may be present in per-
ation of which lies between ACUTE and chronic
ipheral blood, during the invasive stage of infec-
(see CHRONIC DISORDER). An example is sub-
tion. Chemotherapy consists of albendazole.
acute ENDOCARDITIS, a disorder that may not
The formerly used benzimidazole compound,
be diagnosed for several weeks or months, dur-
thiabendazole, is now rarely prescribed in an
ing which time it can severely damage valves in
uncomplicated infection due to unpleasant
the heart.
side-effects; even so, in the hyperinfection syn-
drome it probably remains the more effective
of the two compounds. Subacute Combined
Degeneration of the Cord
Strychnine A degenerative condition of the SPINAL CORD
An alkaloid (see ALKALOIDS) derived from which most commonly occurs as a complica-
Strychnos nux-vomica, the seeds of an East tion of PERNICIOUS ANAEMIA. The motor and
Indian tree, as well as from the seeds of several sensory nerves in the cord are damaged, causing
other closely allied trees and shrubs. It is a white spasticity of the limbs and an unsteady gait.
crystalline body possessed of an intensely bitter Treatment is with vitamin B12 (see APPENDIX 5:
taste, more bitter perhaps than that of any other VITAMINS).
substance, and it is not very soluble in water. It
stimulates all parts of the nervous system, and Subacute Sclerosing
was at one time widely used for this purpose. Panencephalitis
Strychnine poisoning is fortunately rare. It A rare complication of MEASLES due to infec-
shows itself in CONVULSIONS, which come on tion of the brain with the measles virus. It
very speedily after the person has taken the develops 218 years after the onset of the mea-
poison. The mental faculties remain unaffected, sles, and is characterised by mental deterior- S
and the symptoms end in death or recovery ation leading on to CONVULSIONS, COMA and
within a few hours. death. The annual incidence in Britain is about
one per million of the childhood population.
Treatment The patient should be kept The risk of its developing is 525 times greater
quiet. Artificial respiration may be necessary after measles than after measles vaccination (see
and intravenous BENZODIAZEPINES to prevent MMR VACCINE; IMMUNISATION).
convulsions may also be needed. (See POISONS;
also APPENDIX 2: ADDRESSES: SOURCES OF Subarachnoid Haemorrhage
INFORMATION, ADVICE, SUPPORT AND SELF- A haemorrhage into the subarachnoid space in
HELP.) the BRAIN. It is usually the result of rupture of
an ANEURYSM on the CIRCLE OF WILLIS. Head
Stupor injury or intense physical exercise occasionally
See UNCONSCIOUSNESS. cause subarachnoid haemorrhage; the diagnosis
is confirmed by CT scan or by identifying
Stuttering blood in the CEREBROSPINAL FLUID at LUMBAR
See STAMMERING. PUNCTURE. Cerebral ANGIOGRAPHY will
 682 Subarachnoid Space

usually pinpoint the site of bleeding. Treatment into this space. The trapped blood forms a large
is bed rest, life-support measures and pro- blood clot or haematoma within the skull and
cedures to reduce blood pressure; sometimes this causes pressure on the underlying brain.
surgery is carried out but not usually until sev- Bleeding may occur slowly as the result of
eral weeks after the acute episode. About 30 per disease or suddenly as the result of injury.
cent of patients recover fully, whilst some have Headaches, confusion and drowsiness result,
residual disabilities such as EPILEPSY, mental sometimes with paralysis. Medical attention is
deterioration or paralysis. About 50 per cent of required urgently if a serious haematoma occurs
those affected die. soon after injury.

Subarachnoid Space Subinvolution

The space between the arachnoid and the pia A term used to indicate that the womb (see
mater two of the membranes covering the UTERUS) has failed to undergo the usual involu-
BRAIN. (See also MENINGES.) tion, or decrease in size, which naturally takes
place within one month after a child is born.
Subclavian
The name applied to a large artery and vein Subjective
which pass to the upper arm between the collar- A term applied to symptoms, and sensations,
bone and the first rib. perceived only by the affected individual. For
example, numbness is a purely subjective sensa-
Subclinical tion, whilst the jerk given by the leg on tap-
A description of a disease that is suspected but ping the tendon of the knee is an objective
which has not developed sufficiently or is too sign.
mild in form to produce clear signs and symp-
toms in an individual. Even so, damage may be Sublimation
caused to tissues and organs. The conversion of a solid substance into a
vapour and its recondensation. The term is also
Subconscious used in a mental sense for the process of con-
A state of being partially conscious, or the verting instinctive sexual desires to new aims
condition in which mental processes occur and objects devoid of sexual significance.
and outside objects and events are perceived
with the mind nearly or quite unconscious of
Subluxation
A partial dislocation of a joint; the term is
them. Such subconscious impressions or sometimes applied to a sprain.
events may be forgotten at the time but may
nevertheless exert a continued influence over Submucosa
the conscious mind, or may at a subsequent The layer of CONNECTIVE TISSUE that occurs
time come fully into consciousness. Much under a MUCOUS MEMBRANE for example, in
importance is attached to the influence of the intestinal wall.
painful or unpleasant experiences which,
although forgotten, continue to influence the Subphrenic Abscess
mind; these may be a factor in the develop- An ABSCESS that develops under the DIA-
S ment of anxiety states. This injurious influ- PHRAGM, usually on the right side of the abdo-
ence may be reduced when the subconscious men between the liver and the diaphragm. The
impressions come fully into consciousness and cause may be an organ that has perforated for
are then remembered and clearly seen in their instance, a peptic ulcer in the stomach or
relative importance. intestine. An abscess may also occur after an
abdominal operation, usually when the bowel
Subcutaneous or stomach has been operated on. Antibiotics
Anything pertaining to the loose cellular tissue and sometimes surgery are the method of
beneath the SKIN: for example, a subcutaneous treatment.
injection (see HYPODERMIC).
Substrate
Subdural A compound on which an ENZYME acts: for
Relating to the space between the strong outer instance, ribonucleic acid (RNA) is the sub-
layer of the MENINGES, the membranes which strate for ribonuclease (an enzyme that cata-
cover the BRAIN, and the arachnoid, which is lyses the breakdown of ribonucleic acid, a
the middle layer of the meninges. A subdural cellular compound involved in the synthesis of
haemorrhage occurs when bleeding takes place PROTEIN).
 Suicide 683

Succussion Sudeks Atrophy

See THRILL. A clinical technique in which a Osteoporosis (see under BONE, DISORDERS OF)
patient suspected of having excessive fluid in a in the hand or foot which develops quickly as
body cavity usually the stomach or pleural a result of injury, infection or malignant
cavity is gently shaken in order to elicit splash- growth.
ing sounds.
Sudorifics
Suckling Drugs and other agents which produce copious
See INFANT FEEDING.
PERSPIRATION.

Sucrose
Cane sugar. Suffocation
See ASPHYXIA; CHOKING.
Suction
The use of a reduction in pressure to clear away Suicide
fluids or other material through a tube. Suction Self-destruction as an intentional act.
is used to remove blood from the site of a surgi- Attempted suicide is when death does not take
cal operation; it is commonly necessary to place, despite an attempt by the person con-
remove secretions from the airways of newly cerned to kill him or herself; parasuicide is the
born babies to help them breathe. term describing an attempt at suicide that is
really an act to draw attention to the perceived
Sudden Infant Death Syndrome problems of the individual involved.
(SIDS) Societies vary in the degree to which they
Sudden infant death syndrome, or cot death, tolerate individuals acting intentionally to
refers to the unexpected death usually during cause their own death. Apart from among
sleep of an apparently healthy baby. Well some native peoples, particularly the Innuit,
over 1,500 such cases are thought to have suicide is generally viewed pejoratively in
occurred in the United Kingdom each year modern societies. Major religious movements,
until 1992, when government advice was including Catholicism, Judaism and Islam,
issued about laying babies on their backs. The have traditionally regarded suicide as a sin.
figure was 192 in 2002 and continues to fall. Nevertheless, it is a growing phenomenon,
Boys are affected more than girls, and over half particularly among the young, and so has
of these deaths occur at the age of 26 months. become a serious public health problem. It is
More common in lower social classes, the inci- estimated that suicide among young people
dence is highest in the winter; most of the has tripled at least during the past 45
infants have been bottle-fed (see also INFANT years. Worldwide, suicide is the second major
FEEDING). cause of death (after tuberculosis) for women
between the ages of 15 and 44, and the fourth
Causes These are unknown, with possible major killer of men in the same age-group
multiple aetiology. Prematurity and low birth- (after traffic accidents, tuberculosis and vio-
weight may play a role. The sleeping position lence). The risk of suicide rises sharply in old
of a baby and an over-warm environment may age. Globally, there are estimated to be S
be major factors, since deaths have fallen between ten and 25 suicide attempts for each
sharply since mothers were officially advised to completed suicide.
place babies on their backs and not to overheat In the United Kingdom, suicide accounts for
them. Some deaths are probably the result of 20 per cent of all deaths of young people.
respiratory infections, usually viral, which may Around 6,000 suicides are reported annually in
stop breathing in at-risk infants, while others the UK, of which approximately 75 per cent are
may result from the infant becoming by men. In the late 1990s the suicide rate in
smothered in a soft pillow. Faults in the babys England, Wales and Northern Ireland fell, but
central breathing control system (central increased in Scotland and the Republic of Ire-
APNOEA) may be a factor. Other possible factors land. Attempted suicide became significantly
include poor socioeconomic environment; more common, particularly among people
vitamin E deficiency; or smoking, drug addic- under the age of 25: among adolescents in the
tion or anaemia in the mother. Help and advice UK, for example, it is estimated that there are
may be obtained from the Foundation for the about 19,000 suicide attempts annually.
Study of Infant Deaths and the Cot Death Follow-up studies of teenagers who attempt
Society. suicide by an overdose show that up to 11 per
 684 Sulcus

cent will succeed in killing themselves over the have aided and abetted a suicide if they know-
following few years. In young people, factors ingly provide the means or even if they simply
linked to suicide and attempted suicide include provide advice about the toxicity of medication
alcohol or drug abuse, unemployment, physical and tell patients the lethal dosage. Some argue
or sexual abuse, and the fact of being in cus- that the distinction between EUTHANASIA and
tody. (In the mid-1990s, 20 per cent of all physician-assisted suicide has no moral or prac-
prison suicides were by people under 21.) tical relevance, particularly if patients are too
Apart from the young, those at highest risk of disabled to act themselves. In theory, patients
dying by suicide include health professionals, retain ultimate control in cases of assisted sui-
pharmacists, vets and farmers. Self-poisoning cide, whereas control rests with the doctor in
(see POISONS) is the common method used by euthanasia. Surveys of health professionals
health professionals for whom high stress levels, appear to indicate a feeling by some that less
together with relatively easy access to means, are responsibility or culpability attaches to assisting
important factors. The World Health Organisa- suicide than to euthanasia. In a recent UK court
tion has outlined six basic steps for the preven- case (2002), a judge declared that a mentally
tion of suicide, focusing particularly on alert woman on a permanent life-support
reducing the availability of common methods. regime in hospital had a right to ask for the
Although suicide is not a criminal offence in the support system to be switched off. (See also MEN-
UK, assisting suicide is a crime carrying a TAL ILLNESS.)
potential sentence of 14 years imprisonment.
There are several dilemmas faced by health pro- Sulcus
fessionals if they believe that a patient is con- The term applied to any groove or furrow, but
sidering suicide: one is that the provision of especially to a fissure of the BRAIN.
information to the patient may make them an
accessory (see below). A dilemma after suicide is Sulfadiazine
the common demand from insurers for medical A highly active drug which in moderate dosage
information, although, ethically, the duty of produces a high and persistent blood concentra-
confidentiality extends beyond the patients tion. It is relatively non-toxic and is sometimes
death (see ETHICS). (Legally, some disclosure is used to prevent the recurrence of RHEUMATIC
permitted to those with a claim arising from the FEVER.
patients death.) Life-insurance contracts gener-
ally render invalid any claim by the heirs on the Sulfamethoxazole
policy of an individual who commits suicide, so has been used in combination with TRIMETHO-
that disclosure by a doctor often creates ten- PRIM (as co-trimoxazole) to treat infections of
sions with the relatives. Non-disclosure of rele- the URINARY TRACT. Increasing bacterial resist-
vant medical information, however, may result ance to sulphonamides and the incidence of
in a fraudulent insurance claim being made. side-effects means that caution is needed in pre-
scribing co-trimoxazole.
Physician-assisted suicide Although
controversial, a special legal exemption applies Sulfasalazine
to doctors in a few countries who assist termin- A chemical combination of sulphapyridine and
S ally ill patients to kill themselves. Oregon in the 5-aminosalycilic acid. It is used to treat
United States legalised physician-assisted sui- ULCERATIVE COLITIS (valuable as oral therapy
cide in 1997, where it still occurs; assisted for mild symptomatic disease; also available as
suicide was briefly legal in the Australian suppositories for rectal disease) and RHEUMA-
Northern Territory in 1996 but the legislation TOID ARTHRITIS. The salicylate part is now
was repealed. (It is also practised, but not available alone in drugs such as mesalazine and
legally authorised, in the Netherlands and olsalazine. Several reports of blood dyscrasias
Switzerland.) from patients taking these drugs have prompted
In the UK there have been unsuccessful par- the COMMITTEE ON SAFETY OF MEDICINES
liamentary attempts to legalise assisted suicide, (CSM) to recommend that patients with
such as the 1997 Doctor Assisted Dying Bill. In unexplained blood disorders should stop treat-
law, a distinction is made between killing ment and be given an immediate blood count.
people with their consent (classified as murder)
and assisting them to commit suicide (a statu- Sulfinpyrazone
tory offence under the Suicide Act 1961). The A derivative of phenylbutazone which is of
distinction is between acting as a perpetrator value in the prophylaxis and treatment of
and as an accessory. Doctors may be judged to GOUT.
 Suppuration 685

Sulphonylureas transmitter and vasoconstrictor agent. It may

Sulphonylureas are sulphonamide derivatives also be taken orally, but sumatriptan should not
which lower the blood sugar when they are be used within 24 hours of treatment with
given by mouth by enhancing the production ERGOTAMINE, the standard antimigraine
of INSULIN. They are effective in treating DIA- treatment.
BETES MELLITUS only when some residual pan-
creatic beta-cell function is present. All may Summer Diarrhoea
lead to HYPOGLYCAEMIA if given in overdose See DIARRHOEA; INFANT FEEDING.
and this is particularly common when long-
acting sulphonylureas are given to elderly Sunburn
See PHOTODERMATOSES.
patients. There is no evidence for any difference
in the effectiveness of the various sulphonyl-
ureas. TOLBUTAMIDE was the first of the sul-
Super-
A prefix signifying above, or implying excess.
phonlyurea drugs; it has a short duration of
action and is usually given twice daily. CHLOR- Superficial
PROPAMIDE has a more prolonged action and
Positioned near the surface: for example, super-
only needs to be given once daily, but its ficial blood vessels or capillaries lie just beneath
prolonged action causes more side-effects the skin, and by contracting and expanding
including sensitivity reactions. Other oral help to regulate body TEMPERATURE.
hypoglycaemic agents of this family include
glibenclamide, which has a duration of action Supination
intermediate between tolbutamide and chlor- Supination means the turning of the forearm
propamide and also produces side-effects (in and hand so that the palm faces upwards.
about 30 per cent of outpatients, according to a
recent study). Other sulphonlyureas include Supine
acetohexamide, glibornuride, gliclazide, glipiz- Lying on the back, face upwards; or the position
ide, gliquidone and tolazamide. Glymidine is a of the forearm where the hand lies face
related compound with a similar action to the upwards.
sulphonylureas. It is particularly useful in
patients who are hypersensitive to Suppository
sulphonylureas. A drug preparation in solid, bullet-like form,
Sulphonylureas are best avoided in patients which is inserted into the RECTUM (or the
who are overweight, as they tend to stimulate VAGINA, when it is called a pessary). This
the appetite and aggravate obesity. They method of using drugs may be chosen for vari-
should be used with caution in patients with ous reasons. For example, the suppository, as in
hepatic or renal disease. Side-effects are the case of glycerin suppositories, may be used
infrequent and usually not severe, the most to produce an aperient action. Other supposi-
common being epigastric discomfort with tories, such as those of MORPHINE, are used to
occasional nausea, vomiting and anorexia. In reduce pain and check the action of the bowels.
about 10 per cent of patients, chlorpropamide Suppositories are useful when the patient is
and tolbutamide may cause facial flushing after unable to take oral medication and when no
drinking alcohol. Some patients are hypersensi- suitable preparation is available for injection. S
tive to oral hypoglycaemic agents and develop
rashes which may progress to ERYTHEMA multi- Suppression
forme and exfoliative DERMATITIS. These reac- (1) The stopping of any physiological activity.
tions usually appear in the first 68 weeks of (2) A psychological defence mechanism by
treatment. which an individual intentionally refuses to
acknowledge an idea or memory that he or she
Sulphur finds distasteful or unpleasant.
Chemical combinations of this substance were (3) A treatment that stops the visible signs of an
once applied topically because of their anti- illness or holds back its usual progress.
microbial activity; they are no longer used.
Suppuration
Sumatriptan The process of PUS formation. When pus forms
A drug used in the treatment of MIGRAINE on a raw surface the process is called ulceration,
attacks. Given by subcutaneous injection, it whilst a deep-seated collection of pus is known
provides quick relief of pain, acting on the same as an ABSCESS. (See also INFLAMMATION; PHAGO-
receptors as 5-hydroxytryptamine a neuro- CYTOSIS; ULCER; WOUNDS.)
 686 Supra-

Supra- treatment of injuries, deformities or

A prefix signifying above or upon. individual diseases by operation or manipula-
tion. It incorporates: general surgery; special-
Suprapubic ised techniques such as CRYOSURGERY,
An operation in which the abdomen is opened MICROSURGERY, MINIMALLY INVASIVE SURGERY
in its lower part, immediately above the pubic (MIS), or minimal access (keyhole) surgery,
bones. It was a common approach for removal and stereotactic sugery (see STEREOTAXIS);
of the PROSTATE GLAND but is now used less and surgery associated with the main special-
often, as transurethral PROSTATECTOMY has ties, especially cardiothoracic surgery, gastro-
become the standard procedure. (See also enterology, GYNAECOLOGY, NEUROLOGY,
LITHOTOMY.) OBSTETRICS, ONCOLOGY, OPHTHALMOLOGY,
ORTHOPAEDICS, TRANSPLANTATION surgery,
Suprarenal Glands RECONSTRUCTIVE (PLASTIC) SURGERY, and
See ADRENAL GLANDS. UROLOGY. Remotely controlled surgery using
televisual and robotic techniques is also being
Supraventricular Tachycardia developed.
An unusually fast but regular beating of the It takes up to 15 years to train a surgeon from
HEART occurring for periods that may last sev- the time at which he or she enters medical
eral hours or days. In most people with this school; after graduating as a doctor a surgeon
abnormality the heart rate is between 140 and has to pass a comprehensive two-stage examin-
180 beats a minute; rarely, the rate may rise as ation to become a fellow of one of the five rec-
high as 250300 beats. The condition occurs ognised colleges of surgeons in the UK and
when abnormal electrical impulses that arise in Ireland.
the upper chambers (atria) of the heart over- Surgery is carried out in specially designed
ride the normal control centre the sinoatrial operating theatres. Whereas it used to necessi-
node for the heartbeat. Symptoms usually tate days and sometimes weeks of inpatient
include breathlessness, palpitations, pain in the hospital care, many patients are now treated as
chest and fainting. An ELECTROCARDIOGRAM day patients, often under local anaesthesia,
(ECG) is taken to help make the diagnosis. An being admitted in the morning and discharged
acute episode can sometimes be stopped by later in the day.
VALSAVAS MANOEUVRE or by drinking cold More complex surgery, such as transplanta-
water. Anti-arrhythmic drugs (see ARRHYTH- tion and neurosurgery, usually necessitates
MIA) such as adenosine and digoxin are used to patients being nursed post-operatively in high-
treat recurrent attacks. Occasionally, a severe dependency units (see INTENSIVE THERAPY UNIT
attack may need to be treated with an electric (ITU)) before being transferred to ordinary
shock to the heart: this is known as recovery wards. Successful surgery requires close
DEFIBRILLATION. co-operation between surgeons, physicians and
radiologists as well as anaesthetists (see ANAES-
Suramin THESIA), whose sophisticated techniques enable
A drug used to treat trypanosomiasis or SLEEP- surgeons to undertake long and complex oper-
ING SICKNESS. Side-effects vary in frequency ations that were unthinkable 30 or more years
S and intensity and are sometimes serious. They ago. Surgical treatment of cancers is usually
include nausea, vomiting, SHOCK and occasion- done in collaboration with oncologists. Success-
ally loss of consciousness. ful surgery is also dependent on the skills of
supporting staff comprising nurses and
Surfactant operating-theatre technicians and the avail-
A surface-active agent lining the alveoli (see ability of up-to-date facilities.
ALVEOLUS) of the LUNGS, which plays an essen-
tial part in RESPIRATION by preventing the Surrogate
alveoli from collapsing at the end of expiration. A term applied in medicine to a substance used
Absence, or lack, of surfactant is one of the fac- as a substitute for another. The term is also
tors responsible for HYALINE MEMBRANE DIS- applied to a woman who agrees to become
EASE, and it is now being used in the treatment pregnant and give birth to a child on the under-
of this condition by means of instillation into standing that she will give up the child to the
the trachea. parents who have contracted with her for the
surrogacy arrangement. When in vitro fertilisa-
Surgery tion (IVF see under ASSISTED CONCEPTION)
That branch of medicine involved in the proved successful, it became possible to transfer
 Sympathetic 687

a fertilised egg to a uterus of choice. Artificial enables the bloodstream to propel the catheter
insemination of the potential surrogate mother through the right ventricle to the pulmonary
using sperm from the putative father is also artery. The balloon is deflated and the catheter
practised. Surrogacy has thrown up a host of can then record the pulmonary artery pressure.
ethical and legal problems which have yet to be When the balloon is inflated, the tip is isolated
satisfactorily resolved. from the pulmonary artery and measures the
left atrial pressure. These measurements are
Susceptibility important in the management of patients with
A reduced ability to combat an illness, usually circulatory failure, as under these circumstances
an infection. The patient may be in poor gen- the central venous pressure or the right atrial
eral health, or immunisation or disease may pressure is an unreliable guide to fluid-
have affected his or her defence mechanisms. replacement.
For example, a person with AIDS is particularly
susceptible to infection. Sweat
See PERSPIRATION.
Suture
A word used in both an anatomical and a surgi- Sweat Glands
cal sense. (1) Anatomically, suture is a type of See SKIN.
immovable joint, found particularly in the
SKULL, including the coronal suture (between Sweetbread
the frontal and parietal bones); the lamboidal A traditional term applied to several glands
suture (between the parietal and occipital used for food, including the THYMUS GLAND of
bones); and the sagittal suture (between the two young animals (neck sweetbread), the PAN-
parietal bones). (2) Surgically the word refers CREAS (stomach sweetbread), and the testis (see
either to the technique of closing a wound, or TESTICLE).
to the material used. Stitching methods have
been developed for gastrointestinal, neuro- Sycosis Barbae
logical, dermatological and other forms of sur- (Barbers itch.) A chronic staphylococcal fol-
gery, and include laser surgery and removable liculitis (infection of the hair follicles with
clips or staples. The material used is generally staphylococci bacteria see STAPHYLOCOCCUS)
divided into monofilament, twisted or braided. of the beard area in males, causing a papulo-
Absorbable sutures used for internal stitching pustular inflammation clearly centred on hair
include catgut, Vicryl and Dexon. Non- follicles. It must be distinguished from RING-
absorbable sutures include silk, nylon and pro- WORM infection of the face and hair follicles
lene. The type used and time of suture-removal (tinea barbae) and from pseudo-folliculitis due
depend upon the site and general state of the to ingrowing hairs. Topical and oral anti-
patient. Those patients on steroids who have a staphyloccoccal antibiotics are effective.
malignant or infective disorder heal slowly, and
their sutures may need to stay in for 14 days or Sydenhams Chorea
more instead of the usual 58 days. Also called St Vituss dance, this type of CHO-
REA is a disease of the central nervous system
Swab that occurs after RHEUMATIC FEVER up to six S
A term applied to a small piece of gauze, lint or months later and is probably an inflammatory
similar material used for wiping out the mouth complication of a -haemolytic streptococcal
of a patient or for drying out a wound. The infection (see STREPTOCOCCUS). The patient
term is also applied to a tuft of sterilised cotton- presents with jerky, purposeless, involuntary
wool wrapped round a wire and enclosed in a movements of a limb and tongue, similar to the
sterile glass tube used for obtaining a sample symptoms of CEREBRAL PALSY. Chorea is best
for example, from the throat or from wounds treated as a transitory reversible form of cerebral
for bacteriological examination. palsy. The disorder usually lasts 68 months
and residual symptoms are rare.
Swan-Ganz Catheter
(See also CATHETERS.) A flexible tube with a Sympathetic
double lumen and a small balloon at its distal A term applied to certain diseases or symptoms
end. It is introduced into a vein in the arm and which arise in one part of the body in con-
advanced until the end of the catheter is in the sequence of disease in some distant part.
right atrium (see HEART). The balloon is then Inflammation may arise in one eye, in con-
inflated with air through one lumen and this sequence of injury to the other, by the spread of
 688 Sympathetic Nervous System

organisms along the lymphatic channels con- two bones are connected by strong fibrous car-
necting the two, and is then known as sympa- tilage. One example is the joint between the
thetic inflammation. PAIN also may be of a two pubic bones in the front of the pelvis;
sympathetic nature. another, the joint between the upper and
middle parts of the breastbone.
Sympathetic Nervous System
Part of the AUTONOMIC NERVOUS SYSTEM. It Symptom
consists of scattered collections of grey matter A term applied to any evidence of disease. The
known as ganglia, united by an irregular net- term, physical sign, is generally applied to evi-
work of nerve-fibres; those portions where the dence of disease of which the patient does not
ganglia are placed most closely and where the complain but which is elicited upon examin-
network of fibres is especially dense being ation. For the symptoms indicative of the
known as plexuses. The chief part of the sympa- various diseases, see under the headings of each
thetic system consists of two ganglionated cords disease.
that run through the neck, chest, and abdomen,
lying close in front of the spine. In conjunction Syn-
with the other part of the autonomic nervous A prefix signifying union.
system the parasympathetic this part con-
trols many of the bodys involuntary activities Synapse
involving glands, organs and other tissues. (For The term applied to the anatomical relation of
further details, see NERVOUS SYSTEM.) one NEURON(E) (nerve cell) with another which
is effected at various points by contact of their
Sympathomimetic Drugs branching processes. The two neurons do not
These drugs stimulate the activity of the SYM- come directly into contact, but the release of a
PATHETIC NERVOUS SYSTEM. There are three chemical NEUROTRANSMITTER by one neuronal
groups: inotropic and vasoconstrictor sym- AXON is followed by this chemical travelling
pathomimetics, and those used for cardio- across the synapse and firing off the signal along
pulmonary resuscitation. The properties of another nerve. A signal can be sent across a syn-
these drugs vary according to whether they act apse in one direction only, from presynaptic or
on alpha or beta adrenergic receptors. postsynaptic membranes. Synapses are divided
into excitatory and inhibitory types. When a
Inotropics act on beta receptors in heart neurotransmitter travels across an excitatory
muscle (see HEART), increasing its contractility synapse it usually provokes the receptor neuron
and sometimes the heart rate. DOBUTAMINE into initiating an electrical impulse. Inhibitory
and DOPAMINE are cardiac stimulants, while synapses cool down the excitation of the
dopexamine acts on heart muscle and, via per- adjacent neurons. Drugs that influence the
ipheral dopamine receptors, increases the excre- NERVOUS SYSTEM usually do so by affecting
tion of URINE. ISOPRENALINE is used only as the release or modification of the neuro-
emergency treatment of heart block (interrup- transmitters passing across the synapse.
tion of the hearts conduction) or severe slow-
ing of the heart rate (bradycardia). Syncope
S Another word for fainting a loss of conscious-
Vasoconstrictor sympathomimetics ness due to a fall in BLOOD PRESSURE. This may
These drugs temporarily raise the BLOOD result because the cardiac output has become
PRESSURE by constricting peripheral blood ves- reduced, or because the peripheral resistance
sels. Sometimes they are used as a speedy way of provided by the arterioles has decreased. The
raising blood pressure when other treatment has simple faint or vaso-vagal attack is a result of a
failed. EPHEDRINE and methoxamine hydro- failure to maintain an adequate venous return
chloride are examples of this type of of blood to the heart. This is likely to occur
sympathomimetic. after prolonged periods of standing, particularly
if one is standing still or if the climatic condi-
Cardiopulmonary resuscitation ADREN- tions are hot. It can also result from an unpleas-
ALINE (epinephrine) is given intravenously in ant or painful experience. Pallor, sweating and a
cardiac arrest, and other drugs used include slow pulse are characteristic. Recovery is
ATROPINE and CALCIUM. immediate when the venous return is restored
by lying flat.
Symphysis Syncope can also result when the venous
An anatomical description of a joint in which return to the heart is impaired as a result of a
 Syphilis 689

rise in intrathoracic pressure. This may happen MEMBRANE) to treat troublesome SYNOVITIS.
after prolonged vigorous coughing the so- The operation is not normally done until other
called COUGH SYNCOPE or when elderly men treatments have failed.
with prostatic hypertrophy strain to empty their
bladder. This is known as micturition syncope. Synovial Membrane
Syncope is particularly likely to occur when the This forms the lining of the soft parts that
arterial blood pressure is unusually low. This enclose the cavity of a joint. (See JOINTS.)
may result from overtreatment of HYPERTEN-
SION with drugs or it may be the result of dis- Synovitis
eases, such as ADDISONS DISEASE, which are Inflammation of the membrane lining a joint
associated with low blood pressures. It is (see JOINTS). It is usually painful and accom-
important that syncope be distinguished from panied by effusion of fluid within the synovial
EPILEPSY. sac of the joint. It is found in RHEUMATOID
ARTHRITIS, various injuries and inflammations
Syndactyly of joints, and in the chronic form in TUBERCU-
A congenital condition in which two or more LOSIS. Treatment of synovitis is with rest, splint-
fingers or toes are fused together to a varying ing, ANALGESICS and NON-STEROIDAL ANTI-
extent. The condition is popularly known as INFLAMMATORY DRUGS (NSAIDS). Infection
WEBBED FINGERS (or toes). should be treated with ANTIBIOTICS. If the joint
fails to respond, surgery (SYNOVECTOMY) may
Syndrome be needed. (See also JOINTS, DISEASES OF.)
A term applied to a group of symptoms occur-
ring together regularly, and thus constituting a Synovium
disease to which some particular name is given: See SYNOVIAL MEMBRANE.
for example, CUSHINGS SYNDROME comprising
obesity, hypertension, purple striae and osteo- Synthetic
porosis; or KORSAKOFFS SYNDROME, compris- A term applied to substances produced by
ing loss of appreciation of time and place chemical processes in the laboratory or by arti-
combined with talkativeness, forming signs of ficial building-up.
alcoholic delirium.

Synechiae Syphilis
A sexually transmitted or CONGENITAL disease
Adhesions between the iris (see EYE) and
(the latter variety is now rare). Because in most
adjacent structures (e.g. cornea, lens). They
cases the disease is acquired as a result of sexual
usually arise as a result of inflammation of the
intercourse with an infected individual, syphilis
iris.
is classed as one of the SEXUALLY TRANSMITTED
DISEASES (STDS). It normally affects only human
Synergist
(1) A muscle that works in concert with an beings.
AGONIST muscle to perform a certain Today, around 40 million new cases are noti-
movement. fied annually in the world, and this is probably
(2) An agent, for example a drug, that acts with an underestimate. In the UK the annual inci-
another to produce a result that is greater than dence of new cases of syphilis diagnosed in S
adding together the separate effects of the two NHS genito-urinary medicine clinics has risen
agents. Synergism in drug treatment may be from 8.8 to 9.7 per million of male population
beneficial, as in the case of combined LEVO- between 1991 and 1999; among women the
DOPA and SELEGILINE, a selective monoamine figures were 4.0 to 4.5 per million. The infec-
oxidase inhibitor (see MONOAMINE OXIDASE tion is most common in homosexual men (see
INHIBITORS (MAOIS), in the treatment of PAR- HOMOSEXUALITY).
KINSONISM. It may be potentially dangerous,
however, as when MAOIs boost the effects of Causes The causative organism is the
BARBITURATES. Treponema pallidum, a long, thread-like wavy
organism with pointed tapering ends. It is
Synostosis found in large numbers in the sores in the pri-
The term applied to a union by bony material mary stage of the disease and in the skin lesions
of adjacent bones which are normally separate. in the secondary stage.
Syphilis may be acquired from people already
Synovectomy suffering from the disease, or it may be con-
Surgical removal of the synovium (see SYNOVIAL genital. The acquired form is usually got by
 690 Syringe

sexual intercourse, kissing or other intimate Still later, effects are apt to follow, such as
bodily contact. The epithelium covering the disease of the arteries, leading to ANEURYSM (see
general surface of the skin seems to be an effi- also ARTERIES, DISEASES OF), to STROKE, and to
cient protection, but the infective material mental deterioration (see MENTAL ILLNESS); also
penetrates mucous membranes. The acquired certain nervous diseases, of which tabes dorsalis
form of the disease is infectious from contact and general paralysis are the chief.
with sores, both in its primary and secondary The congenital form of syphilis, now rare,
stages; infants suffering from the congenital may affect the child before birth, leading then
form are also highly infectious. Accordingly, as a rule to miscarriage or to a stillbirth if born
anyone frequently handling such an infant is at at full time. Alternatively he (or she) may show
risk of infection, although the mother may the first symptoms a few weeks after birth, the
handle the baby with impunity. appearances then corresponding to the second-
ary manifestations of the acquired form.
Symptoms The acquired form of the disease Laboratory confirmation of a clinical diag-
is commonly divided into three stages pri- nosis is done by identifying active spirochaetes
mary, secondary, and tertiary (although the lat- (see SPIROCHAETE) in a smear taken at the site of
ter is much less common than it was 50 years the initial chancre, and by blood tests such as
ago). The clinical manifestations are varied and the treponomal antibody absorption tests.
are sometimes confused with those of other dis- These tests are strongly positive at the second-
eases. There are several laboratory tests for con- ary stage, and in patients with neurosyphilis the
firming the diagnosis. tests may have to be done on CEREBROSPINAL
The incubation period ranges from ten to 90 FLUID.
days, although most frequently it is around four
weeks. Then, a small persistent ULCER appears Treatment Any person with syphilis is a
at the site of infection, which is accompanied source of infection, and should take precautions
by a typical cartilaginous hardness of the tissues not to spread it. PENICILLIN is the drug of
immediately around and beneath it. This, choice in the disease in all its stages, but resist-
which is known as the primary sore (or chan- ant strains of the Treponema pallidum have
cre), may be very much inflamed, or it may be emerged and are causing problems, especially in
so small as to pass almost or quite unnoticed. A developing countries. Treatment must be insti-
few days later, the lymphatic glands in its tuted as soon as possible after infection is
neighbourhood, and then those all over the acquired: (1) a full course of treatment is
body, become swollen and hard. This condition essential in every case, no matter how mild the
lasts for several weeks before the sore slowly disease may appear to be; (2) periodic blood
heals and the glands subside. After a variable examinations must be carried out on every
period usually about two months from the patient for at least two years after he or she has
date of infection the secondary symptoms been apparently cured.
appear and resemble the symptoms of an ordin- Prevention is important and promiscuous
ary FEVER, with pyrexia, loss of appetite, vague hetero- or homosexual intercourse involves a
pains through the body, and a faint red rash risk of infection. Condoms provide some, but
seen best upon the front of the chest. People not complete protection. Infection can be
S with syphilis are infectious in the primary and avoided by maintaining a monogamous
secondary stages but not in the latent or tertiary relationship.
stages.
In untreated or inadequately treated cases, Syringe
manifestations of the tertiary stage develop An instrument for injecting fluid into, or with-
after the lapse of some months or even years: drawing fluid from, a body cavity, tissue or
this is known as the latent period. These consist blood. Syringes come in different sizes and
in the growth, at various sites throughout the some are specially designed for use in a particu-
body, of masses of granulation tissue known as lar site for example, for withdrawing CERE-
gummas. These gummas may appear as hard BROSPINAL FLUID. The basic design is the same:
nodules in the skin, or form tumour-like a calibrated barrel with a plunger at one end,
masses in the muscles, or produce thickening of while the other end has a nozzle to which a
bones. They may develop in the brain and hollow needle can be attached. Most syringes
spinal cord, where their presence causes very are disposable, plastic, presterilised and packed
serious symptoms. Gummas yield readily, as a in sealed containers. Injections can be given
rule, to appropriate treatment, and generally under the skin, into muscle, into a vein or into
disappear speedily. the cerebrospinal fluid. The term hypodermic,
 Systolic Pressure 691

though literally meaning under the skin, is now system attacks CONNECTIVE TISSUE, causing
used to describe most syringes. severe inflammation. As connective tissue is
widely distributed, the skin and many organs
Syringe Drivers are affected. Recent research suggests that the
Battery or mains electrically driven portable autoimmune response is triggered by a failure in
devices into which a SYRINGE can be loaded to the bodys mechanism for clearing up the debris
give a continuous INFUSION to patients who of dead cells. The affected person lacks an
need regular treatment to control severe pain, ENZYME called D Nase 1 which degrades DNA.
or to newborns where the volume to be given is This discovery should enable people who are at
critical and difficult to control with other high risk of developing SLE to be detected and
devices. treated early with D Nase 1. Sunlight, viral
infections and certain drugs can induce some of
Syringomyelia the symptoms, especially in older people.
A rare disease affecting the SPINAL CORD, in Symptoms of SLE and also of discoid lupus
which irregular cavities form, surrounded by an erythematosus (DLE) come and go with vary-
excessive amount of the connective tissue of the ing levels of severity. SLE produces character-
central nervous system. These cavities encroach istic red, blotchy rash over the cheeks and
upon the nerve-tracts in the cord, producing bridge of the nose. Patients feel ill, are fatigued
especially loss of the sense of pain or of that for and feverish with appetite loss, nausea, joint
heat and cold in parts of the limbs, although the pain and loss of weight. Some develop ARTH-
sensation of touch is retained. Another occa- RITIS, ANAEMIA, kidney failure, neurological
sional symptom is wasting of certain muscles in or psychiatric problems, PLEURISY and
the limbs. Changes affecting outlying parts like PERICARDITIS.
the fingers are also found. Because of their
insensitiveness to pain, these are often burnt or Treatment D Nase 1 offers promising
injured; troublesome ulcers, or loss of parts of possibilities for treating SLE. Recognised
the fingers, may result. The condition of the treatment has been aimed at reducing
spinal cord is probably present at birth, inflammation and alleviating symptoms. NON-
although the symptoms do not usually appear STEROIDAL ANTI-INFLAMMATORY DRUGS
until adulthood. The disease is slowly progres- (NSAIDS) help to reduce joint pains; anti-
sive, although sudden exacerbations may occur malarial drugs reduce the skin rash; and COR-
after a cough, a sneeze, or sudden straining. TICOSTEROIDS combat fever, pleurisy and
Treatment is supportive for this progressive neurological symptoms. If patients develop ser-
disorder. ious kidney or neurological damage, CYTO-
TOXIC immunosuppressant drugs should be
Systemic given, The disease is life-threatening if the
A description of something for example, a kidneys are seriously affected; otherwise the
drug that affects the whole body and not just prospect for people with SLE has improved
part of it. greatly in recent years.

Systemic Lupus Erythematosus Systole

(SLE) The contraction of the HEART. It alternates with S
A serious and potentially fatal autoimmune dis- the resting phase, known as DIASTOLE. The two
ease occurring predominantly in women (see also occupy, respectively, about one-third and two-
LUPUS Lupus erythematosus). The disorder is thirds of the cycle of heart action.
found worldwide, although its incidence is
higher in some ethnic groups such as Afro- Systolic Pressure
Caribbeans and Chinese. The bodys immune See BLOOD PRESSURE.
 Tactile

T Perceptible to, pertaining to or related to the

sense of TOUCH.

Taenia
A parasitic tapeworm that infects several ani-
mals including humans (see TAENIASIS).
Tabes
This means, literally, a wasting disease, and is a
traditional name applied to various diseases Taeniasis
such as tabes dorsalis (tertiary SYPHILIS) and A parasitic disorder caused by taeniae or
TUBERCULOSIS accompanied by enlargement of
tapeworms.
glands (see GLAND). In the case of infestation with Taenia sagi-
nata, the host may not have any symptoms and
only become aware that he or she is infested
Tablet upon sight of the tapeworm or rather, part of
A solid, disc-like preparation made by compres- it in the stools (FAECES). In the case of Taenia
sion of a powder and containing a drug or drugs solium the outlook is more serious because the
mixed usually with sugar and other material. eggs, when swallowed, are liable to migrate into
Tablets are widely used because of their con- the tissues of the body (as they do in the pig)
venience and accurate dosage. and cause hydatid cysts. If these occur in the
muscles they may cause little trouble but, if
TAB Vaccine they occur in the brain or liver, they can prove
A combined VACCINE administered to produce very serious.
IMMUNITY against typhoid and paratyphoid A Hydatid cysts often grow to a great size,
and B (see ENTERIC FEVER). (See also budding off smaller cysts in their interior. The
IMMUNISATION.) symptoms produced by a hydatid cyst depend
mainly upon the effects of its size and con-
Tacalcitol sequent pressure.
A recently introduced, once-daily topical
preparation for the treatment of plaque Treatment of tapeworm infestation is the
PSORIASIS. administration (on a named-patient basis) of
niclosamide or praziquantal. Hydatid disease is
Tachycardia treated by surgical removal, sometimes in
A rise in the heart rate above the normal range coordination with albendazole.
at rest 60100 beats a minute sometimes
accompanied by irregularities in rhythm Talc
(ARRHYTHMIA). Sinus tachycardia may occur Talc is a soft mineral consisting of magnesium
with exercise or emotional excitement, but it silicate. It is much used as an ingredient of dust-
may be the result of a feverish illness. (See also ing powders.
HEART, DISEASES OF.)

Talipes
Tachyphylaxis Also known colloquially as club-foot, this is a
Rapidly developing TOLERANCE to a drug. deformity apparent at birth, affecting the ankle
and foot: the foot is twisted at the ankle-joint so
Tachypnoea that the sole does not rest on the ground when
Unusually rapid breathing. standing. The heel may be pulled up so that the
individual walks on the toes (talipes equinus);
Tacrolimus the toes may be bent up and the heel used for
An IMMUNOSUPPRESSANT drug used for pri- walking (talipes calcaneus); the sole may be
mary immunosuppression in recipients of kid- twisted inwards (varus) or outwards (valgus); or
ney or liver transplants (see TRANSPLANTATION) the individual may have a combination of
where the natural rejection process has been deformities (equinovarus). The condition is
resistant to conventional immunosuppression probably the result of genetic predisposition
regimens such as CORTICOSTEROIDS, AZATHIO- with an environmental trigger. In the UK the
PRINE and CICLOSPORIN A. It is also used, with incidence is one in 1,000 live births and talipes
caution, in some severe cases of eczema (see is more common in boys than in girls, with 10
DERMATITIS). per cent of sufferers having a first-degree rela-
 Target Cell 693

tive with the same condition. Clinically, there a potentially dangerous but fortunately
are two types of congenital talipes equinovarus uncommon reaction.
(CTEV): a milder form resolving CTEV in
which full correction to the normal position is Tamponade
relatively easily achieved; and a more severe type A potentially life-threatening compression of
resistant CTEV which is harder to correct; the HEART by the accumulation of fluid in the
and the infant has reduced calf-muscle bulk and pericardial sac (see PERICARDIUM) for example,
abnormally shaped bones. blood after a penetrating knife wound. This is
characterised by TACHYCARDIA, PULSUS PARA-
Treatment should be started at birth with DOXUS, low blood pressure, raised pressure in
the foot corrected to an improved position and the jugular vein, and abnormally quiet heart
then maintained in plaster of Paris or strapping sounds.
a procedure performed weekly or more often.
If the deformity is not corrected by around six Treatment consists of draining the fluid
weeks of age, a decision has to be made about (which may be blood or an effusion) and treat-
whether to carry out surgical correction. If a ing the underlying cause.
deformity persists to maturity, a triple arthrodo-
sis fusion of three affected joints may be Tannin
required. Tannin, or tannic acid, is an uncrystallisable
white powder, soluble in water or glycerin. It is
Talus extracted from oak galls in large amount, but it
The square-shaped bone which forms the lower is also present in almost all vegetable infusions.
part of the ankle-joint and unites the leg bones Tannic acid acts as an astringent.
to the foot.
Tantulum
Tamoxifen A heavy metal that is used in surgery because it
An OESTROGENS receptor antagonist namely, is easy to mould and does not corrode. It is
the drug blocks the action of oestrogen particularly suitable for repairing defects in the
which is the treatment of choice for breast can- SKULL bones.
cer (see BREASTS, DISEASES OF) in postmeno-
pausal women in conjunction with LUMP- Tapeworm
ECTOMY or partial or complete MASTECTOMY. See TAENIASIS.
Around 30 per cent of patients in whom breast
cancer has spread to adjacent glands or beyond Tapotement
respond to this hormonal treatment. In A MASSAGE technique in which a part of the
patients with tumours that are oestrogen- body is hit repeatedly and quickly with the
sensitive, the positive response to tamoxifen is hands. The technique is useful in helping
60 per cent; those tumours that are not patients with BRONCHITIS to loosen the MUCUS
oestrogen-sensitive are much less likely to in the air passages of their lungs, thus helping
respond to the drug. Tamoxifen increases both them to cough it up.
survival rates and the period between the diag-
nosis of the tumour and appearance of meta- Tapping
static growth (see METASTASIS) in tumours sen- The popular name for the withdrawal of
sitive to it. The drug has fewer adverse effects OEDEMA fluid from the cavities or the sub- T
than most others used for treating breast can- cutaneous tissues of the body. (See also
cer. Patients in whom the cancer has spread to ASPIRATION.)
the bone(s) may suffer pain with tamoxifen
treatment. Tardive Dyskinesia
Tamoxifen is also used to treat INFERTILITY, Also known as orofacial DYSKINESIA, this is
being taken on certain days of the menstrual characterised by involuntary chewing and
cycle (see MENSTRUATION). grimacing, usually the result of years of taking
ANTIPSYCHOTIC DRUGS, particularly in the eld-
Tampon erly when these drugs are sometimes used to
A plug of compressed gauze or cotton wool sedate troublesome patients.
inserted into a wound or orifice to arrest bleed-
ing. Also inserted into the VAGINA to absorb the Target Cell
flow of blood during MENSTRUATION. Infected Abnormal ERYTHROCYTES which are large and
tampons may cause TOXIC SHOCK SYNDROME, floppy and have a ringed appearance, similar
 694 Target Organ

to that of a target, when stained and viewed matching the colour of skin grafts (see GRAFT).
under the microscope. This change from nor- It is performed by implanting particles of col-
mal may occur with iron-deficiency ANAEMIA, our pigment into the deeper layer of the skin
liver disease, a small SPLEEN, haemoglobinopa- known as the corium (see SKIN). This is done by
thies (disorders of HAEMOGLOBIN), and means of a needle or needles. The main medical
THALASSAEMIA. hazard of tattooing is infection, particularly
A target cell is also a cell that is the focus of HEPATITIS. The tattooed person may also
attack by macrophages (killer cells see MACRO- become allergic to one of the pigments used,
PHAGE) or ANTIBODIES; it may also be the site particularly cinnabar. Removal, which should
of action of a specific hormone (see be done by a plastic surgeon, always leaves a
HORMONES). residual scar, and often needs to be followed by
a skin graft. Removal is not allowed under the
Target Organ National Health Service unless there is some
The specific organ (or tissue) at which a hor- medical reason: for example, allergic reactions
mone (see HORMONES), drug or other agent is to it. Other methods of removal are by CRYO-
aimed to bring about its physiological or SURGERY, DERMABRASION and laser surgery.
pharmacological effect. These, too, must only be carried out under
skilled medical supervision.
Tars In order to reduce the health hazards, tattoo-
Complex oily mixtures derived from coal or ists along with acupuncturists, cosmetic skin-
wood (pine). Prolonged exposure to some crude piercers and hair electrolysers are required by
tars occupationally may lead to multiple cuta- UK legislation to register their premises with
neous warty lesions (pitch warts). Squamous health and local authorities before starting
carcinoma may supervene. More refined business. The practitioners have to satisfy the
extracts of tar are used in dermatological authorities that adequate precautions have been
therapy, especially in PSORIASIS. taken to prevent the transmission of infections.

Tarsal Taxanes
Of or pertaining to the TARSUS of the foot and A group of CYTOTOXIC drugs administered
ankle this comprises TALUS, calcaneus navicu- intravenously for the treatment of advanced
lar, cuboid and three cuneiform bones or ovarian cancer (see OVARIES, DISEASES OF) and
eyelid (see EYE). secondary spread of breast cancer (see BREASTS,
DISEASES OF). Given under specialist supervi-
Tarsus sion in hospital, taxanes are not effective for
The region of the instep with its seven bones, all patients but results are encouraging when
the chief of which are the TALUS supporting the they do respond. Side-effects include HYPER-
leg-bones and the CALCANEUS or heel-bone, the SENSITIVITY, MYELOSUPPRESSION, cardiac
others being the navicular, cuboid, and three ARRHYTHMIA, and peripheral NEUROPATHY.
cuneiform bones. Examples of the taxanes are PACLITAXEL and
DOCETAXEL.
Tartar
A concretion that forms on the TEETH near the Taxis
margin of the gum, consisting chiefly of phos- The method of pushing back, into the abdom-
T phate of lime deposited from the saliva. Mixed inal cavity, a loop of bowel which has passed
with this are food particles, and this is an ideal through the wall in consequence of a rupture.
medium for bacteria to flourish in. Regular
brushing of the teeth is a preventive measure. Tay Sachs Disease
Dentists or dental hygienists routinely remove An inherited recessive condition in which there
tartar, because it gives rise to wasting of the is abnormal accumulation of lipids (see LIPID) in
gums and loosening of the teeth. the BRAIN. The result is blindness, mental
retardation and death in early childhood. The
Taste disease can usually be prevented by genetic
See TONGUE. counselling in those communities in which the
disease is known to occur.
Tattooing
This has been a cult, or fashion, since the earli- Tazarotene
est days of history. Apart from the mixed A RETINOIDS preparation recently introduced
motives for its use, it has a therapeutic use in for the topical treatment of PSORIASIS. It is
 Teeth 695

applied in the evening and continued for up to

six weeks. Tazarotene is not suitable for those
aged under 18.

T-Cell Lymphoma
See LYMPHOMA.

Tears
See EYE Lacrimal apparatus.

Technetium-99
An ISOTOPE of the artificial element tech-
netium. It emits gamma rays and is used as a
tracer in building up a scintigraphic radioactive
image of organs such as the brain.

Teeth
Hard organs developed from the mucous mem-
branes of the mouth and embedded in the jaw-
bones, used to bite and grind food and to aid
clarity of speech.

Structure Each tooth is composed of

enamel, dentine, cement, pulp and periodontal
membrane.
ENAMEL is the almost translucent material
which covers the crown of a tooth. It is the most Vertical section through incisor tooth.
highly calcified material in the body, 9697 per
cent being composed of calcified salts. It is composed of a highly vascular, delicate fibrous
arranged from millions of long, six-sided prisms tissue with many fine nerve-fibres. The pulp is
set on end on the dentine (see below), and is very sensitive to temperature variation and to
thickest over the biting surface of the tooth. touch. If the pulp becomes exposed it will
With increasing age or the ingestion of abrasive become infected and usually cannot overcome
foods the teeth may be worn away on the sur- this. Root-canal treatment or extraction of the
face, so that the dentine becomes visible. The tooth may be necessary.
outer sides of some teeth may be worn away by PERIODONTAL MEMBRANE This is a layer of
bad tooth-brushing technique. fibrous tissue arranged in groups of fibres which
DENTINE is a dense yellowish-white material surround and support the root of a tooth in a
from which the bulk and the basic shape of a bone socket. The fibres are interspersed with
tooth are formed. It is like ivory and is harder blood vessels and nerves. Loss of the membrane
than bone but softer than enamel. The crown of leads to loss of the tooth. The membrane can
the tooth is covered by the hard protective release and re-attach the fibres to allow the
enamel and the root is covered by a bone-like tooth to move when it erupts, or (to correct
substance called cement. Decay can erode den- dental deformities) is being moved by ortho- T
tine faster than enamel (see TEETH, DISORDERS dontic springs.
OF Caries of the teeth).
CEMENT or cementum is a thin bone-like Arrangement and form Teeth are pres-
material which covers the roots of teeth and ent in most mammals and nearly all have two
helps hold them in the bone. Fibres of the peri- sets: a temporary or milk set, followed by a
odontal membrane (see below) are embedded in permanent or adult set. In some animals, like
the cement and the bone. When the gums the toothed whale, all the teeth are similar; but
recede, part of the cement may be exposed and in humans there are four different shapes: inci-
the cells die. Once this has happened, the peri- sors, canines (eye-teeth), premolars (bicuspids),
odontal membrane can no longer be attached to and molars. The incisors are chisel-shaped and
the tooth and, if sufficient cement is destroyed, the canine is pointed. Premolars have two cusps
the tooth-support will be so weakened that the on the crown (one medial to the other) and
tooth will become loose. molars have at least four cusps. They are
PULP This is the inner core of the tooth and is arranged together in an arch in each jaw and the
 696 Teeth

mesoderm. This is the dental lamina, and from

it ten smaller swellings in each jaw appear.
These become bell-shaped and enclose a part of
the mesoderm, the cells of which become spe-
cialised and are called the dental papillae. The
epithelial cells produce enamel and the dental
papilla forms the dentine, cement and pulp. At
a fixed time the teeth start to erupt and a root is
formed. Before the deciduous teeth erupt, the
permanent teeth form, medial to them. In due
course the deciduous roots resorb and the per-
manent teeth are then able to push the crowns
out and erupt themselves. If this process is dis-
turbed, the permanent teeth may be displaced
and appear in an abnormal position or be
impacted.
Eruption of teeth is in a definite order and at
The permanent teeth of the left side of upper and
a fixed time, although there may be a few
lower jaws. months leeway in either direction which is of
no significance. Excessive delay is found in
some congenital disorders such as CRETINISM.
cusps of opposing teeth interdigitate. Some It may also be associated with local abnormal-
herbivores have no upper anterior teeth but use ities of the jaws such as cysts, malformed teeth
a pad of gum instead. As each arch is sym- and supernumerary teeth.
metrical, the teeth in an upper and lower quad- The usual order of eruption of deciduous
rant can be used to identify the animal. In teeth is:
humans, the quadrants are the same: in other
words, in the child there are two incisors, one Middle incisors 68 months
canine and two molars (total teeth 20); in the Lateral incisors 810 months
adult there are two incisors, one canine, two First molars 1216 months
premolars and three molars (total 32). This Canines (eye-teeth) 1620 months
mixture of tooth-form suggests that humans are Second molars 2030 months
omnivorous. Anatomically the crown of the
tooth has mesial and distal surfaces which touch
The usual order of eruption of permanent
the tooth next to it. The mesial surface is the
teeth is:
one nearer to the centre line and the distal is
the further away. The biting surface is called the
First molars 67 years
incisal edge for the anterior teeth and the
Middle incisors 68 years
occlusal surface for the posteriors.
Lateral incisors 79 years
Canines 912 years
Development The first stage in the forma- First and second premolars 1012 years
tion of the teeth is the appearance of a down- Second molars 1113 years
growth of EPITHELIUM into the underlying Third molars (wisdom teeth) 1721 years
T

Teeth of a six-year-old child. The permanent teeth are coloured black.

 Teeth, Disorders of 697

have receded. This pain is often associated with

temperature-change or sweet foods. Expert den-
tal advice should be sought early, before the
decay is extensive. If a large cavity is accessible,
temporary relief may be obtained by inserting a
small piece of cotton wool soaked, for example,
in oil of cloves.

Alveolar abscess, dental abscess or

gumboil This is an ABSCESS caused by an
infected tooth. It may be present as a large
swelling or cause trismus (inability to open the
mouth). Treatment is drainage of the PUS,
extraction of the tooth and/or ANTIBIOTICS.

Caries of the teeth or dental decay is very

common in the more affluent countries and is
most common in children and young adults.
Increasing awareness of the causes has resulted
in a considerable improvement in dental health,
particularly in recent years; this has coincided
with a rise in general health. Now more than
half of five-year-old children are caries-free and
of the others, 10 per cent have half of the
remaining carious cavities. Since the start of the
National Health Service, the emphasis has been
on preventive dentistry, and now edentulous
The permanent teeth of the upper (top) and lower patients are mainly found among the elderly
(bottom) jaws.
who had their teeth removed before 1948.
The cause of caries is probably acid produced
Teeth, Disorders of by oral bacteria from dietary carbohydrates,
particularly refined sugar, and this dissolves part
Teething, or the process of eruption of the of the enamel; the dentine is eroded more
teeth in infants, may be accompanied by irrit- quickly as it is softer (see TEETH Structure).
ability, salivation and loss of sleep. The child The exposed smooth surfaces are usually pro-
will tend to rub or touch the painful area. Relief tected as they are easily cleaned during normal
may be obtained in the child by allowing it to eating and by brushing. Irregular and over-
chew on a hard object such as a toy or rusk. crowded teeth are more at risk from decay as
Mild ANALGESICS may be given if the child is they are difficult to clean. Primitive people who
restless and wakens in the night. A serious pit- chew coarse foods rarely get caries. Fluoride in
fall is to assume that an infants symptoms of the drinking water at about one part per million
ill-health are due to teething, as the cause may is associated with a reduction in the caries rate.
be more serious. Fever and fits (see SEIZURE) are Prolonged severe disease in infancy is associ- T
not due to teething. ated with poor calcification of the teeth, mak-
ing them more vulnerable to decay. As the teeth
Toothache is the pain felt when there is are formed and partly calcified by the time of
inflammation of the pulp or periodontal mem- birth, the diet and health of the mother are also
brane of a tooth (see TEETH Structure). It can important to the teeth of the child. Pregnant
vary in intensity and may be recurring. The mothers and children should have a good bal-
commonest cause is caries (see below) when the anced diet with sufficient calcium and vitamin
cavity is close to the pulp. Once the pulp has D. A fibrous diet will also aid cleansing of the
become infected, this is likely to spread from teeth and stimulate the circulation in the teeth
the apex of the tooth into the bone to form an and jaws. The caries rate can be reduced by
abscess (gumboil see below). A lesser but more regular brushing with a fluoride toothpaste two
long-lasting pain is felt when the dentine is or three times per day and certainly before
unprotected. This can occur when the enamel is going to sleep. The provision of sweet or sugary
lost due to decay or trauma or because the gums juices in an infants bottle should be avoided.
 698 Teeth-Grinding

Irregularity of the permanent PEPSIA. Treatment is largely aimed at stabilising

teeth may be due to an abnormality in the the condition rather than curing it.
growth of the jaws or to the early or late loss of
the deciduous set (see TEETH Development). Dental abscess is an infection that arises in
Most frequently it is due to an imbalance in the or around a tooth and spreads to involve the
size of the teeth and the length of the jaws. bone. It may occur many years after a blow has
Some improvement may take place with age, killed the pulp of the tooth, or more quickly
but many will require the help of an ortho- after caries has reached the pulp. At first the
dontist (specialist dentist) who can correct pain may be mild and intermittent but eventu-
many malocclusions by removing a few teeth to ally it will become severe and a swelling will
allow the others to be moved into a good pos- develop in the gum over the apex of the tooth.
ition by means of springs and elastics on various A radiograph of the tooth will show a round
appliances which are worn in the mouth. clear area at the apex of the tooth. Treatment
may be by painting the gum with a mild
Loosening of the teeth may be due to an counter-irritant such as a tincture of aconite
accident or inflammation of the GUM. Teeth and iodine in the early stages, but later root-
loosened by trauma may be replaced and canal therapy or apicectomy may be required. If
splinted in the socket, even if knocked right a swelling is present, it may need to be drained
out. If the loosening is due to periodontal dis- or the offending teeth extracted and antibiotics
ease, the prognosis is less favourable. given.

Discoloration of the teeth may be intrinsic Injuries to teeth are common. The more
or extrinsic: in other words, the stain may be in minor injuries include crazing and the loss of
the calcified structure or stuck on to it. Intrinsic small chips of enamel, and the major ones
staining may be due to JAUNDICE or the anti- include a broken root and avulsion of the entire
biotic tetracycline. Extrinsic stain may be due tooth. A specialist dental opinion should be
to tea, coffee, tobacco, pan (a mixture of chuna sought as soon as possible. A tooth that has
and betel nuts wrapped in a leaf ), iron- been knocked out can be re-implanted if it is
containing medicines or excess fluoride. clean and replaced within a few hours. It will
then require splinting in place for 46 weeks.
Gingivitis or inflammation of the gum may
occur as an acute or chronic condition. In the Prevention of dental disease As with
acute form it is often part of a general infection other disorders, prevention is better than cure.
of the mouth, and principally occurs in chil- Children should be taught at an early age to
dren or young adults resolving after 1014 keep their teeth and gums clean and to avoid
days. The chronic form occurs later in life and refined sugars between meals. It is better to fin-
tends to be progressive. Various micro- ish a meal with a drink of water rather than a
organisms may be found on the lesions, includ- sweetened drink. Fluoride in some of its forms
ing anaerobes. Antiseptic mouthwashes may is useful in the reduction of dental caries; in
help, and once the painful stage is past, the some parts of the UK natural water contains
gums should be thoroughly cleaned and any fluoride, and in some areas where fluoride con-
calculus removed. In severe conditions an anti- tent is low, artificial fluoridation of the water
biotic may be required. supply is carried out. Overcrowding of the
T teeth, obvious maldevelopment of the jaw and
Periodontal disease is the spread of gin- persistent thumbsucking into the teens are all
givitis (see above) to involve the periodontal indications for seeking the advice of an ortho-
membrane of the tooth; in its florid form it dontist. Generally, adults have less trouble with
used to be called pyorrhoea. In this, the mem- decay but more with periodontal disease and, as
brane becomes damaged by the inflammatory its onset is insidious, regular dental inspections
process and a space or pocket is formed into are desirable.
which a probe can be easily passed. As the
pocket becomes more extensive, the tooth loos- Teeth-Grinding
ens. The loss of the periodontal membrane also See also BRUXISM. Teeth-grinding occurs in chil-
leads to the loss of supporting bone. Chronic dren during sleep and is of no significance
inflammation soon occurs and is difficult to unless really persistent. During the day it may
eradicate. Pain is not a feature of the disease but be an attention-seeking device. There is no
there is often an unpleasant odour (halitosis). treatment for it.
The gums bleed easily and there may be DYS- In adults it is usually associated with stress or
 Temperature 699

anxiety, but may be due to some local condition planes, where it may be difficult or impossible
in the mouth such as an unsatisfactory filling. It to get a doctor to the patient. It can also speed
may also be caused by certain drugs, including up the referral process, reduce unnecessary
fenfluramine and LEVODOPA. If not controlled, referrals and improve communication between
it produces excessive wear of the enamel cover- professionals. It has potential value in pilot
ing of the teeth. Treatment consists of allevi- projects of hospital at home care.
ation of any condition in the mouth and any
anxiety and stress. Temazepam
A benzodiazepine anxiolytic (see BENZO-
Teething DIAZEPINES; ANXIOLYTICS) derived from diaze-
See under TEETH, DISORDERS OF. pam. To be used with care for short-term
treatment of insomnia, generally associated
Teichopsia with difficulty in falling asleep, frequent noc-
This refers to zigzag lines that patients with turnal awakening or early-morning awakening.
MIGRAINE often experience as a visual AURA Temazepam is a relatively quick-acting hyp-
preceding an attack. notic of short duration, so although there is
little hangover the next morning compared
Teicoplanin with other hypnotics there may still be some
A glycopeptide antibiotic (see ANTIBIOTICS) drowsiness and effect on skilled tasks such as
which acts against aerobic and anaerobic gram- driving. It should be avoided in elderly people
positive (see GRAMS STAIN) bacteria. Like the who are at risk of becoming ataxic and so liable
similar drug, VANCOMYCIN, it is given in the to falling and injuring themselves. Temazepam
prophylaxis and treatment of ENDOCARDITIS is often abused by drug addicts.
and other serious infections caused by gram-
positive cocci, including STAPHYLOCOCCUS, Temperature
which have developed resistance to other anti- Body temperature is the result of a balance of
biotics. Its long duration of action means that it heat-generating forces, chiefly METABOLISM and
need be given only once a day. Teicoplanin can muscular activity, and heat-loss, mainly from
be given intramuscularly or intravenously. Its blood circulation through and evaporation
use should be carefully monitored as there is a from the skin and lungs. The physiological pro-
range of adverse effects. cess of homeostasis a neurological and hor-
monal feedback mechanism maintains the
Telangiectasis healthy persons body at the correct tempera-
Abnormal dilatation of ARTERIOLES and venules ture. Disturbance of temperature, as in disease,
(see VENULE). In the skin it is seen in spider may be caused by impairment of any of these
NAEVUS and ROSACEA particularly. bodily functions, or by malfunction of the
controlling centre in the brain.
Telemedicine In humans the normal temperature is
A broad term used to describe medicine at a around 37 C (984 F). It may rise as high as
distance through a communications link. 43 C or fall to 32 C in various conditions, but
Although distance education has been used suc- the risk to life is only serious above 41 C or
cessfully for some time, more recently distance below 35 C.
diagnosis and treatment have been successfully Fall in temperature may accompany major
piloted. In teleradiology, radiographic images loss of blood, starvation, and the state of col- T
are transmitted to a distant site for interpret- lapse (see SHOCK) which may occur in severe
ation by a radiologist. A telepathologist can FEVER and other acute conditions. Certain
look down, and in some cases control, a micro- chronic diseases, notably hypothyroidism (see
scope located several hundred miles away. In a THYROID GLAND, DISEASES OF), are generally
teleconsultation, the doctor and patient are in accompanied by a subnormal temperature.
different places, joined by a communications Increased temperature is a characteristic of
link such as medical videoconferencing. In its many acute diseases, particularly infections;
simplest form, this kind of telemedicine uses indeed, many diseases have a characteristic pat-
the telephone; more recently, full-colour tern that enables a provisional diagnosis to be
two-way video and audio links have been used. made or acts as a warning of possible complica-
Telesurgery, combining televisual and robotic tions. In most cases the temperature gradually
techniques, is also under development. abates as the patient recovers, but in others,
Telemedicine is useful for remote locations, such as PNEUMONIA and TYPHUS FEVER, the
such as the Antartic, or on board ships, or aero- untreated disease ends rapidly by a CRISIS in
 700 Temple

which the temperature falls, perspiration breaks cerebral activity originates in the temporal lobe
out, the pulse rate falls, and breathing becomes of the BRAIN. It is characterised by hallucin-
quieter. This crisis is often preceded by an ations of smell and sometimes of taste, hearing,
increase in symptoms, including an epicritical or sight. There may be disturbances of mem-
rise in temperature. ory, including dj vu phenomena. AUTOMA-
Body temperature is usually measured on the TISM may occur, but consciousness is seldom
Celsius scale, on a thermometer reading from lost.
35 C to 433 C. Measurement may be taken
in the mouth (under the tongue), in the armpit, Tenderness
the external ear canal or (occasionally in Pain experienced when a diseased part is
infants) in the rectum. (See also THERMOMETER.) handled.

Treatment Abnormally low temperatures Tendinitis

may be treated by application of external heat, Inflammation of a TENDON. Usually caused by
or reduction of heat loss from the body surface. unusual or excessive physical activity, it may
High temperature may be treated in various also be infective in origin or secondary to a
ways, apart from the primary treatment of the connective-tissue disorder. The pain and
underlying condition. Treatment of hyper- inflammation may be treated with NON-
thermia or hypothermia should ensure a grad- STEROIDAL ANTI-INFLAMMATORY DRUGS
ual return to normal temperature (see (NSAIDS), immobilisation splinting, and STER-
ANTIPYRETICS. OID injections. Repetitive strain injury (RSI),
caused by constant use of a keyboard (type-
Temple writer, word processor or computer), is tendin-
The side of the head above the line between the itis occurring in the hands and arms (see UPPER
eye and ear. The term, temporal, is applied to LIMB DISORDERS).
the muscles, nerves, and artery of this region.
The hair usually begins to turn grey first at the Tendon
temples. A tendon also known as sinew, or leader is
the cord of tissue that attaches the end of a
Temporal muscle to the bone or other structure upon
Referring or relating to the temporal region (see which the muscle acts when it contracts. Ten-
TEMPLE). dons are composed of bundles of white fibrous
tissue arranged in a very dense manner, and
Temporal Arteritis are of great strength. Some are rounded, some
Inflammation of the TEMPORAL ARTERY. Also flattened bands, whilst others are very short
known as giant cell arteritis, it often affects the muscle-fibres being attached almost dir-
other arteries too, mainly in the head. It pre- ectly to the bone. Most tendons are sur-
dominantly affects the elderly. The artery rounded by sheaths lined with membrane
becomes tender with reddening of the overlying similar to the SYNOVIAL MEMBRANE lining
skin; headache and blindness may also occur. joint-cavities: in this sheath the tendon glides
The diagnosis is confirmed by temporal artery smoothly over surrounding parts. The fibres of
BIOPSY, and treatment is with steroids (see a tendon pass into the substance of the bone
STEROID). and blend with the fibres composing it. One
T of the largest tendons in the body is the Achil-
Temporal Artery les tendon, or tendo calcaneus, which attaches
A branch of the external carotid artery that is the muscle of the calf to the calcaneus or heel-
the main vessel supplying blood to the temple bone.
and scalp.
Tendon injuries are one of the hazards of
Temporal Lobe sports (see SPORTS MEDICINE). They usually
Part of the cerebral cortex in each hemisphere of result from indirect violence, or overuse, rather
the BRAIN. Areas of the temporal lobe are than direct violence.
involved in the understanding of sound and
spoken language. Rupture usually results from the sudden
application of an unbalanced load. Thus, com-
Temporal Lobe Epilepsy plete rupture of the Achilles tendon is com-
More accurately called complex partial seizures, mon in taking an awkward step backwards
this is a type of EPILEPSY in which the abnormal playing squash. There is sudden pain; the
 Terbinafine 701

victim is often under the impression that he or Tenotomy

she has received a blow. This is accompanied An operation in which one or more tendons (see
by loss of function, and a gap may be felt in TENDON) are divided, usually with the object of
the tendon. remedying some deformity.
Partial Rupture is also accompanied by
pain, but there is no breach of continuity or Tenovaginitis
complete loss of function. Treatment of a com- See TENDOVAGINITIS.
plete rupture usually means surgical repair fol-
lowed by immobilisation of the tendon in plas- TENS
ter of Paris for six weeks. Partial rupture usually See TRANSCUTANEOUS ELECTRICAL NERVE
responds to physiotherapy and immobilisation, STIMULATION (TENS).
but healing is slow.
Tentorium
Tendon Transfer A wide flap of DURA MATER forming a partition
Reconstructive surgery in which the TENDON between the cerebrum and cerebellum (see
from an unimportant muscle is removed and BRAIN) and supporting the former.
used to repair or replace a damaged tendon of a
major muscle.
Teratogenesis
Tendovaginitis The production of physical defects in the
Also called tenovaginitis: inflammation of a FETUS. A drug may interfere with a mechanism
TENDON and of the sheath enveloping it. that is essential for growth, and result in
arrested or distorted development of the fetus
Tenesmus and yet cause no disturbance in adults, in
A symptom of disease affecting the lower part whom these growth processes have ceased.
of the large INTESTINE, such as DYSENTERY, Whether and how the EMBRYO is affected
piles (HAEMORRHOIDS) or tumour. It consists depends on what stage of development it has
of a constant sense of heavy discomfort about reached when the drug is given. The age of early
the lower bowel and desire to defaecate, differentiation that is, from the beginning of
coupled with straining when doing so, with the the third week to the end of the tenth week of
passage of mucus and often blood. pregnancy is the time of greatest susceptibil-
ity. After this time the likelihood of CON-
Tennis Elbow GENITAL malformation resulting from drug
The medical name for this condition is epi- treatment is less, although the death of the fetus
condylitis. The condition is characterised by can occur at any time as a result of drugs cross-
pain and tenderness on the outside of the elbow ing the PLACENTA or as a result of their effect on
and is the result of inflammation in the TEN- the placental circulation.
DON that attaches the muscles which extend the Although the risks are nil or very small with
elbow to the HUMERUS bone. Epicondylitis can most drugs, no medication should be given to a
be the result of playing a lot of tennis or other pregnant woman, particularly during the first
racquet sports, gardening, do it yourself work, few months of pregnancy, unless it is absolutely
or any activity that constantly pulls the tendon essential for her health or that of her unborn
at its point of attachment. Lifting heavy objects child. Alcohol is regarded as medication in this
aggravates the condition. Treatment is resting context. T
the arm, ANALGESICS and/or NON-STEROIDAL
ANTI-INFLAMMATORY DRUGS (NSAIDS). Some- Teratoma
times ULTRASOUND therapy may promote heal- A tumour that consists of partially developed
ing, but persistent severe pain may necessitate embryonic tissues. The most common sites of
the local injection of CORTICOSTEROIDS. this tumour are the ovary (see OVARIES) and the
Rarely, surgery may be recommended to release TESTICLE.
the tendon.

Teno- Terbinafine
A prefix denoting some relation to a TENDON. An antifungal drug given systemically. Used in
the treatment of dermatophyte infections of the
Tenosynovitis nails and RINGWORM infections (tinea pedis,
Also called tenositis: inflammation of a cruris and corporis) which have not responded
TENDON. to topical antifungal preparations.
 702 Terbutaline

Terbutaline sexual characteristics (growth of the genitals,

A beta2 adrenoreceptor agonist that acts breast and adult hair distribution). The cause
as a BRONCHODILATOR (see also BETA- may be hereditary or the result of a disorder of
ADRENOCEPTOR-BLOCKING DRUGS). As an the PITUITARY GLAND which produces GON-
aerosol (see INHALANTS), it is of particular value ADOTROPHINS that stimulate development of
in the treatment of mild to moderate attacks of the testes and ovaries.
ASTHMA; it is also available in oral and par-
enteral forms, as well as subcutaneous, intra- Varicocoele is distension of the veins of the
muscular, or slow intravenous injection. spermatic cord, especially on the left side, the
causes being similar to varicose veins elsewhere
Tertian Fever (see VEINS, DISEASES OF). The chief symptom is
The name applied to that type of MALARIA in a painful dragging sensation in the testicle,
which the fever reappears every other day. especially after exertion. Wearing a support
provides relief; rarely, an operation may be
Testicle advisable. Low sperm-count may accompany a
Every man has two testicles or testes which are varicocele, in which case surgical removal may
the sexual glands. In the fetus, they develop in be advisable.
the abdomen, but before birth they descend
into a fold or pouch of skin known as the Orchitis or acute inflammation may arise
SCROTUM. Each testicle consists of up to 1,000 from CYSTITIS, stone in the bladder, and
minute tubes lined by cells from which the inflammation in the urinary organs, especially
spermatozoa (see SPERMATOZOON) are formed. GONORRHOEA. It may also follow MUMPS.
Around 45 million spermatozoa are produced Intense pain, swelling and redness occur; treat-
per gram of testicle per day. These tubes com- ment consists of rest, support of the scrotum,
municate with one another near the centre of analgesics as appropriate, and the administra-
the testicle, and are connected by a much coiled tion of antibiotics if a definitive micro-
tube, the EPIDIDYMIS, with the ductus, or VAS organism can be identified. In some patients the
DEFERENS, which enters the abdomen and condition may develop and form an ABSCESS.
passes on to the base of the bladder. This duct,
after joining a reservoir known as the seminal Torsion or twisting of the spermatic cord is
vesicle, opens, close to the duct from the other relatively common in adolescents. About half
side of the body, into the URETHRA where it the cases occur in the early hours of the morn-
passes through the PROSTATE GLAND. Owing to ing during sleep. Typically felt as pain of vary-
the convolutions of these ducts leading from ing severity in the lower abdomen or scrotum,
the testicles to the urethra, and their indirect the testis becomes hard and swollen. Treatment
route, the passage from testicle to urethra is consists of immediate undoing of the torsion by
over 6 metres (20 feet) in length. In addition to manipulation. If done within a few hours, no
producing spermotozoa, the testicle also forms harm should ensue; however, this should be fol-
the hormone TESTOSTERONE which is respon- lowed within six hours by surgical operation to
sible for the development of male ensure that the torsion has been relieved and to
characteristics. fix the testes. Late surgical attention may result
in ATROPHY of the testis.
Testicle, Diseases of
T The SCROTUM may be affected by various skin Tuberculosis may occur in the testicle, espe-
diseases, particularly eczema (see DERMATITIS) cially when the bladder is already affected.
or fungal infection. A HERNIA may pass into the Causing little pain, the infection is often far
scrotum. Defective development of the testicles advanced before attracting attention. The con-
may lead to their retention within the abdo- dition generally responds well to treatment with
men, a condition called undescended testicle. a combination of antituberculous drugs (see
also main entry for TUBERCULOSIS).
Hydrocoele is a collection of fluid distend-
ing one or both sides of the scrotum with fluid. Tumours of the testes occur in around 600
Treatment is by withdrawal of the fluid using a males annually in the United Kingdom, and are
sterile syringe and aspiration needle. the second most common form of malignant
growth in young males. There are two types:
Hypogonadism Reduced activity of the SEMINOMA and TERATOMA. When adequately
testes or ovaries (male and female gonads). The treated the survival rate for the former is 95 per
result is impaired development of the secondary cent, while that for the latter is 50 per cent.
 Tetanus 703

Injuries A severe blow may lead to SHOCK wound, which is absorbed through the motor
and symptoms of collapse, usually relieved by nerves into the spinal cord where it renders the
rest in bed; however, a HAEMATOMA may nerves excitable and acutely sensitive to mild
develop. stimuli.

Testis Symptoms Most commonly appearing

See TESTICLE. within four to five days of the wound, the
patients symptoms may be delayed for several
Test Meal weeks by which time the wound may have
(1) The name given to a gastric-function test, healed. Initially there is muscle stiffness around
involving injection of HISTAMINE a powerful the wound followed by stiffness around the jaw,
stimulator of gastric juice, or pentagastin. After leading to lockjaw, or trismus. This extends to
the stimulant has been injected, the digestive the muscles of the neck, back, chest, abdomen,
juices are withdrawn through a stomach tube and limbs, leading to strange, often changing,
(inserted through the nose and throat) and their contorted postures, accompanied by frequent
volume and chemistry measured. A similar test seizures often provoked by quite minor stim-
is used to assess the working of the PANCREAS. uli such as a sudden noise. The patients breath-
(2) The second meaning (also called test ing may be seriously affected, in severe cases
feed) applies to a diagnostic procedure for con- leading to ASPHYXIA; the temperature may rise
genital PYLORIC STENOSIS, whereby a paediatri- sharply, often with sweating; and severe pain is
cian feels over the babys abdomen while he or common. Mental clarity is characteristic adding
she is feeding. The pyloric mass can be felt as a to the patients anxiety. In severe infections
firm swelling with the consistency of a squash death may be from asphyxia, PNEUMONIA, or
ball, which comes and goes under the examin- general exhaustion. More commonly, the dis-
ers fingers. ease takes a chronic course, leading to gradual
recovery. Outcome depends on several factors,
Testosterone chiefly the patients immune status and age,
The principal male sex hormone secreted by the and early administration of appropriate
testes. It has also been prepared synthetically treatment.
and has the formula C19H28O2. In true male Tetanus may occur in newborn babies, par-
HYPOGONADISM it has the power of restoring ticularly when birth takes place in an
male sexual characteristics. (See also ANDROGEN.) unhygienic environment. It is particularly
common in the tropics and developing coun-
Test-Tube tries, with a high mortality rate. Local tetanus is
A tube of thin glass closed at one end, which is a rare manifestation, in which only muscles
used for observing chemical reactions or for around the wound are affected, though stiffness
bacterial culture. may last for several months. STRYCHNINE poi-
soning and RABIES, although similar in some
Test-Tube Baby respects to tetanus, may be easily distinguished
See EMBRYO TRANSFER. by taking a good history.

Tetanus Prevention and treatment The incidence

Also called LOCKJAW, this is a bacterial infection of tetanus in the United Kingdom has been
of the nervous system. Increased excitability of almost abolished by the introduction of tetanus T
the SPINAL CORD results in painful and pro- vaccine (see IMMUNISATION). Children are rou-
longed spasms of the voluntary muscles tinely immunised at two, three and four
throughout the body, rapidly leading to death months of age, and boosters are given later in
unless treated. life to at-risk workers, or those travelling to
tropical parts.
Causes The disease is caused by the bacillus Treatment should be started as soon as pos-
Clostridium tetani, found generally in earth and sible after sustaining a potentially dangerous
dust and especially in places where animal wound. An intravenous injection of antitoxin
manure is collected. Infection usually follows a should be given immediately, the wound thor-
wound, especially a deeply punctured or gun- oughly cleaned and PENICILLIN administered.
shot wound, with the presence of some foreign Expert nursing is most important. Spasms may
body. It is a hazard in war and also among farm- be minimised by reducing unexpected stimuli,
ers, gardeners and those in the construction and diazepam (see BENZODIAZEPINES; TRAN-
industry. The bacillus develops a toxin in the QUILLISERS) is helpful. Intravenous feeding
 704 Tetany

should be started immediately if the patient woman is pregnant as the infants deciduous
cannot swallow. Aspiration of bronchial secre- teeth will be stained.
tions and antibiotic treatment of pneumonia
may be necessary. Tetralogy of Fallot
The most common form of cyanotic con-
Tetany genital heart disease. The tetralogy consists of
A condition characterised by SPASM of muscle, stenosis of the pulmonary valve (see PULMON-
usually caused by a fall in blood CALCIUM ARY STENOSIS); a defect in the septum separat-
levels. This results in hyperexcitability of ing the two ventricles (see VENTRICLE); the
muscles which may go into spasm at the AORTA over-riding both ventricles; marked
slightest stimulus. This is well demonstrated in HYPERTROPHY of the right ventricle. Surgery is
two of the classical signs of the disease: required to remedy the defects.
Chvosteks sign, in which the muscles of the
face contract when the cheek is tapped over Tetraplegia
the facial nerve as it emerges on the cheek; and PARALYSIS of the bodys four limbs, also called
Erbs sign, in which muscles go into spasm in quadriplegia.
response to an electrical stimulus which nor-
mally causes only a contraction of the muscle. Thalamus
Tetany occurs in newborn babies, especially if (Plural: thalami.) One of two masses of grey
they are premature, and in infants; as a result matter lying on either side of the third ventricle
of RICKETS, excessive vomiting, or certain of the BRAIN. It is an important relay and
forms of NEPHRITIS. It may also be due to lack coordinating station for sensory impulses such
of the active principle of the PARATHYROID as those for sight.
glands. Overbreathing may also cause it.
Treatment consists of the administration of Thalassaemia
calcium salts, and in severe cases this is done Also known as Cooleys anaemia, this is a con-
by giving calcium gluconate intravenously or dition characterised by severe ANAEMIA, due to
intramuscularly. High doses of vitamin D are an abnormal form of HAEMOGLOBIN in the
also required. blood. It is an inherited disease which is widely
spread across the Mediterranean through the
Tetrabenazine Middle East and into the Far East. It has a par-
A drug used mainly to control disorders of ticularly high incidence in Greece and in Italy.
movement in HUNTINGTONS CHOREA and The abnormal haemoglobin prevents the
similar disorders. It probably acts by reducing affected red cells from functioning properly.
DOPAMINE at the NERVE endings, thus slowing This results in the anaemia. The SPLEEN
neural transmissions. enlarges and abnormalities occur in the BONE
MARROW. If someone inherits the disease from
Tetracyclines both parents, he or she is seriously affected but,
A group of broad-spectrum ANTIBIOTICS if only one parent had the abnormal gene (see
which include oxytetracycline, tetracycline, GENES), the person could well be free of symp-
doxycycline, lymecycline, minocycline, and toms. The severe form of the disorder is called
demeclocycline. thalassaemia major and affected individuals
All the preparations are virtually identical, need repeated blood transfusions as well as
T being active against both gram-negative and treatment to remove excessive iron from their
gram-positive bacteria (see GRAMS STAIN). body. The disease can be diagnosed by prenatal
Derived from cultures of streptomyces bacteria, investigation.
their value has lessened owing to increasing
resistance to the group among bacteria. How- Thalidomide
ever, they remain the treatment of choice for A sedative and hypnotic drug long withdrawn
BRUCELLOSIS, LYME DISEASE, TRACHOMA, PSIT- from the market because it causes TERATOGEN-
TACOSIS, Q FEVER, SALPINGITIS, URETHRITIS ESIS. If taken during the first trimester of preg-
and LYMPHOGRANULOMA INGUINALE, as well as nancy it may cause an unusual limb deformity
for infections caused by MYCOPLASMA, certain in the fetus known as phocomelia (seal or
rickettsiae (see RICKETTSIA) and CHLAMYDIA. flipper extremities).
Additionally they are used in the treatment of
ACNE, but are not advised in children under 12 Thallium
as they may produce permanent discoloration An element that is toxic to nerve and liver tis-
of the teeth. Tetracyclines must not be used if a sues. A poisoned victims hair falls out and does
 Thiamine 705

not regrow. Treatment is the administration of changes in temperature in a record known as a

CHELATING AGENTS. (See also POISONS.) thermogram. Unfortunately, such hot areas of
The radio-isotope (see ISOTOPE) thallium- skin are caused by a number of other condi-
201 is used as a tracer during special imaging tions; this is therefore a diagnostic method that
studies of blood flow through the heart muscle can be used only as a rough screening
in the diagnosis of myocardial ischaemia (see procedure.
HEART, DISEASES OF.)
Thermoluminescent Dosimeter
Theca A commonly used device for measuring
A sheath-like structure enclosing an organ or peoples exposure to RADIATION. It contains
part. activated sodium fluoride which luminesces in
proportion to the radiation dose to which it is
Thenar Eminence exposed.
The projecting mass at the base of the thumb:
what is popularly known as the ball of the Thermometer
thumb. An instrument for measuring a persons body
TEMPERATURE. A traditional clinical therm-
Theophylline ometer comprises a glass capillary tube sealed at
An alkaloid (see ALKALOIDS) structurally similar one end with a MERCURY-filled bulb at the
to CAFFEINE, and found in small amounts in other. The mercury expands (rises) and con-
tea. Its main use is for the relief of BRONCHOS- tracts (falls) according to the temperature of the
PASM, where beta-2 adrenoceptor stimulants bulb, which may be placed under the tongue or
have failed. It is given intravenously in combin- arm or in the rectum. Calibration is in degrees
ation with the stabilising agent ethylenediamine Celsius or Fahrenheit. Modern thermometers
(as aminophylline) for the treatment of severe use an electric probe linked to a digital read-out
ASTHMA or paroxysmal nocturnal DYSPNOEA. display, providing an instant reading. Hospitals
Formerly used in the treatment of left ven- now have electronic devices that maintain con-
tricular failure, it has been largely superseded by stant monitoring of patients temperatures,
more effective DIURETICS. When indicated, pulse rates and blood pressure.
aminophylline should be given by very slow
intravenous injection; acute overdose may cause Thermometer Scales
convulsions and cardiac ARRHYTHMIA. See TEMPERATURE.

Therapeutic Index Thermoreceptor

In anticancer therapy, this is the ratio of a dose The end of a sensory NERVE that reacts to
of the treatment agent that damages normal changes in temperature. Such receptors are
cells to the dose necessary to produce a deter- widely distributed in the SKIN as well as the
mined level of anticancer activity. The index mucous membranes of the mouth and throat.
shows the effectiveness of the treatment against
the cancer. Thiabendazole
The drug of choice for adults infected with the
Therapeutics intestinal parasite Strongyloides stercoralis (see
The general name applied to different methods STRONGYLOIDIASIS). Its side-effects, including
of treatment and healing. ANOREXIA, nausea, vomiting, diarrhoea, T
abdominal pain, itching and drowsiness, are
Therapy more troublesome in elderly patients.
The treatment of injury or disease.
Thiamine
Thermo- The British Pharmacopoeia name for vitamin
A prefix implying some relation to heat. B1. Also known as ANEURINE, it is found in the
husks of cereal grains. Its deficiency may be
Thermography produced by too careful milling of rice, or by a
A method of detecting the amount of heat pro- diet of white bread to the exclusion of brown
duced by different parts of the body. This is bread and other cereal sources of this vitamin.
done with an infra-red sensitive photographic The resulting disease is a form of NEURITIS with
film. High blood flow in an area shows up as a muscular weakness and heart failure known as
heat zone and thus tumours such as breast can- BERIBERI. The best sources of this vitamin are
cer can be identified. The process records such wholemeal flour, bacon, liver, egg-yolk, yeast
 706 Thiazides

and the pulses. The daily requirement is deeply placed between the muscles, and at the
dependent, among other things, upon the total knee they lie behind the joint. The great saphe-
food intake, and has been estimated to be in the nous vein lies near the surface and can be seen
region of 05 mg of thiamine per 1,000 calories, towards the inner side of the thigh passing up to
increased during pregnancy to 2 mg daily as a the groin, where it joins the femoral vein. The
minimum. (See APPENDIX 5: VITAMINS.) femoral nerve accompanies the large vessels and
controls the muscles on the front and inner side
Thiazides of the thigh; while the large sciatic nerve lies
Thiazides are a group of moderately potent close to the back of the femur and supplies the
DIURETICS which are effective when taken by muscles at the back of the thigh and muscles
mouth. They act by inhibiting the reabsorption below the knee.
of sodium and chloride in the renal tubules. Deep wounds on the inner side of the thigh
They also have a blood-pressure-lowering are dangerous by reason of the risk of damage
effect. Chlorothiazide was the first member of to the large vessels. Pain in the back of the
this group to be introduced. Their main use is thigh is often due to inflammation of the sci-
to relieve OEDEMA in heart failure. atic nerve (see SCIATICA). The veins on the inner
All thiazides are active by mouth with an side of the thigh are specially liable to become
onset of action within 12 hours, and a dur- dilated.
ation of 1224 hours. Chlorthalidone is a
thiazide-related compound that has a longer Thiopentone Sodium
duration of action and only requires to be given An intravenous barbiturate whose main use is
on alternate days. The other thiazide drugs for inducing ANAESTHESIA, which it does
available include bendrofluazide, cyclopenthi- rapidly and painlessly.
azide, hydrochlorothiazide, hydroflumethiazide,
indapamide, mefruside, methychlothiazide, Thioridazine
metolazone, polythiazide and xipamide. A tranquilliser that is a useful antipsychotic
drug. (See NEUROLEPTICS.)
Thiazolidinedione Drugs
A group of drugs used to treat type-2 diabetes Thiotepa
(see under DIABETES MELLITUS) which work by One of a dozen or so ALKYLATING AGENTS used
suppressing the activity of RESISTIN, a recently to treat malignant disease. It is especially effect-
discovered hormone that acts against INSULIN. ive for cancer of the bladder. (See also
Resistin links obesity to type-2 diabetes which CYTOTOXIC.)
has long been known to be associated with
overweight subjects. Thirst
The sensation of thirst is generally felt at the
Thierschs Graft back of the throat, because, when there is a
The term given to a method of SKIN-GRAFTING deficiency of water in the system, the throat and
(see also GRAFT) in which strips of skin are shaved mouth especially become parched by evapor-
from a normal area and placed on a burned, ation of moisture from their surface. Thirst is
injured or scarred area to be grafted. increased by heat, and is a constant symptom of
FEVER; it is also present in diseases which
Thigh remove a considerable amount of fluid from the
T The portion of the lower limb above the knee. system, such as diarrhoea, DIABETES MELLITUS
The thigh is supported by the femur or thigh- and DIABETES INSIPIDUS, and after great loss of
bone, the longest and strongest bone in the blood by haemorrhage. A demand for water is
body. A large four-headed muscle, the quadri- also a feature of many conditions associated
ceps, forms most of the fleshy mass on the front with prolonged exertion, severe exhaustion and
and sides of the thigh and serves to straighten DEHYDRATION.
the leg in walking as well as to maintain the
erect posture of the body in standing. At the Thoracic Duct
back of the thigh lie the hamstring muscles; on The large lymph vessel which collects the con-
the inner side the adductor muscles, attached tents of the lymphatics proceeding from the
above to the pelvis and below to the femur, pull lower limbs, the abdomen, the left arm, and left
the lower limb inwards. The large femoral ves- side of the chest, neck, and head. It is provided
sels emerge from the abdomen in the middle of with numerous valves, and opens into the
the groin, the vein lying to the inner side of the veins at the left side of the neck. (See GLAND;
artery. These pass downwards and inwards LYMPHATICS.)
 Thromboembolism 707

Thoracocentesis cavity into which the nose, mouth, gullet, and

The withdrawal of fluid from the pleural cavity. larynx all open. (See also TONSILS; NOSE.)
(See ASPIRATION.)
Throbbing
Thoracoplasty See PULSATION.
The operation of removing a varying number
of ribs so that the underlying lung collapses. It Thrombin
was formerly done to treat pulmonary See COAGULATION.
TUBERCULOSIS.
Thromboangiitis Obliterans
Thorax Also known as Buergers disease, this is an
Another name for the CHEST. Also the title of a inflammatory disease involving the blood ves-
medical journal read by chest physicians. sels and nerves of the limbs, particularly the
lower limbs. TOBACCO is an important cause.
Thought Disorders Pain is the outstanding symptom, accompanied
Thought is a mental activity by which people by pallor of the affected part; intermittent
reason, solve problems, form judgements and CLAUDICATION caused by a reduction in blood
communicate with each other by speech, writ- supply is common. Sooner or later ulceration
ing and behaviour. Disturbances of thought and GANGRENE tend to develop in the feet or
are reflected in how a person communicates: hands when AMPUTATION of the affected part
the normal logic of thought is broken up and may be necessary. There is no specific treat-
a person may randomly move from one sub- ment, but, if seen in the early stages, consider-
ject to another. SCHIZOPHRENIA is a mental able relief may be given to the patient. Regular
illness characterised by thought disorder. Con- walking exercise is helpful and affected indi-
fusion, DEMENTIA, DEPRESSION and MANIA are viduals should not smoke.
other conditions in which thought disorders
may be a marked feature. (See also MENTAL Thrombocyte
ILLNESS.) See PLATELETS.

Threadworm Thrombocytopenia
See ENTEROBIASIS. A fall in the number of PLATELETS (thrombo-
cytes) in the blood caused by failure of produc-
Threonine tion or excessive destruction of platelets. The
One of the essential or indispensable AMINO result is bleeding into the skin (PURPURA), ser-
ACIDS. ious bleeding after injury and spontaneous
bruising. (See also IDIOPATHIC THROMBOCYTO-
Threshold PENIC PURPURA (ITP).)
The degree of stimulation, or electrical depolar-
isation, necessary to produce an action poten- Thrombocytopenic
tial in a nerve-fibre (see NEURON(E); NERVE). See THROMBOCYTOPENIA.
Stimulation below this level elicits no con-
ducted impulse, and supramaximal stimulation Thromboembolism
will elicit the same response as a threshold The formation of a thrombus (BLOOD CLOT) in
stimulus. one part of the circulatory system from which a T
portion becomes detached and lodges in
Thrill another blood vessel, partially or completely
A tremor or vibration felt on applying the hand obstructing the blood flow (an EMBOLISM).
to the surface of the body. It is felt particularly Most commonly a thrombus is formed in the
over the region of the heart in conditions in veins of the leg DEEP VEIN THROMBOSIS (DVT)
which the valve openings are narrowed or an and the embolism lodges in the pulmonary
ANEURYSM is present. (lung) circulation. PULMONARY EMBOLISM is a
potentially fatal condition and requires urgent
Throat anticoagulant treatment (see ANTICOAGULANTS)
In popular language, this is a vague term and sometimes surgery. Extended periods lying
applied indifferently to the region in front of in bed or prolonged sitting in a confined pos-
the neck, to the LARYNX or organ of voice, and ition such as a car or aeroplane can cause DVT;
to the cavity at the back of the mouth. The venous thromboses in the legs may occur after
correct use of the word denotes the PHARYNX or surgery and preventive anticoagulant treatment
 708 Thrombolysis

with HEPARIN and warfarin is often used. Simi- Thrombosis of a coronary artery of the heart
lar treatment is needed if a thrombus develops. is a very serious condition which affects, as a
STREPTOKINASE is also used to treat rule, middle-aged or elderly people.
thromboembolism. (See also ARTERIES, DISEASES OF; COAGULA-
TION; HEART, DISEASES OF Coronary throm-
Thrombolysis bosis; VEINS, DISEASES OF.)
The breakdown of a BLOOD CLOT by enzymic
activity (see ENZYME). Naturally occurring Thromboxane
enzymes limit the enlargement of clots, and A substance produced in the blood PLATELETS
drugs for example, STREPTOKINASE may be which induces aggregation of platelets and
given to dissolve clots (e.g. following a coron- thereby THROMBOSIS. It is also a vaso-
ary THROMBOSIS see under HEART, DISEASES constrictor (a substance that causes the
OF). The drug needs to be given within 612 constriction of blood vessels).
hours to be effective in reducing the death rate,
so prompt diagnosis and transfer to hospital is Thrombus
essential: a short door-to-needle time. An A BLOOD CLOT. Usually describing the forma-
unwanted effect may be increased risk of bleed- tion of a clot within a vessel obstructing the
ing, especially in the elderly. It has been used in flow of blood, but it can also describe blood
trials in patients with PULMONARY EMBOLISM which has escaped from a damaged vessel and
and with peripheral arterial disease, but its value clotted in the surrounding tissue. (See also
in these conditions is uncertain. THROMBOSIS.)

Thrombolytic Agents Thrush

These are compounds with the property of
See CANDIDA.
breaking up blood clots in the circulatory sys-
tem (see BLOOD CLOT; THROMBUS; THROM-
BOSIS; FIBRINOLYTIC DRUGS). Thumb-Sucking
Also called finger-sucking, this is a universal
Thrombophlebitis and harmless habit in infancy. It is usually given
Inflammation of the veins combined with clot up gradually during the pre-school period, but
formation. (See BLOOD CLOT; VEINS, DISEASES quite often persists after school age especially
OF.) if the child is tired, lonely or unhappy. In these
cases the remedy is to deal with the cause. It is
Thromboplastin cruel to use threats or punishment to try to stop
Also known as thrombokinase, this is an the habit.
ENZYME formed in the preliminary stages of the
COAGULATION of blood. It converts the inactive Thymocyte
PROTHROMBIN into the enzyme THROMBIN. A cell that develops in the THYMUS GLAND,
probably from a stem cell of bone marrow. It is
Thrombosis a precursor of T-lymphocytes originating in the
The formation of a BLOOD CLOT within the gland (see LYMPHOCYTE).
vessels or heart during life. The process of clot-
ting within the body depends upon the same Thymoma
T factors as that of clotting of blood outside the A tumour of the THYMUS GLAND. Such
body, involving the fibrinogen and calcium salts tumours are rare and are classified according to
circulating in the blood, as well as blood PLATE- the variety of thymus tissue from which they
LETS. The indirect cause of thrombosis is usu- develop. Epithelial thymomas grow slowly and
ally some damage to the smooth lining of the rarely spread. If the tumour arises from
blood vessels brought about by inflammation, LYMPHOID TISSUE, it may progress to a general-
or the result of ATHEROMA, a chronic disease of ised non-Hodgkins LYMPHOMA. Another var-
the vessel walls. The blood is also specially iety is a thymic TERATOMA which is normally
prone to clot in certain general conditions such benign in women but malignant in men. Thy-
as ANAEMIA, the ill-health of wasting diseases momas may affect the working of the immune
like cancer, and in consequence of the poor cir- system (see IMMUNITY), increasing the likeli-
culation of old age. hood of infection. They are also associated with
Thrombosis may occur in the vessels of the MYASTHENIA GRAVIS an autoimmune dis-
brain and thus causes STROKE in people whose order; removal of the gland may cure the
arteries are much diseased. disorder.
 Thyroid Gland, Diseases of 709

Thymus Gland to destroy any residual cancerous cells. If treated

The thymus gland was given its name by Galen early, the outlook is good.
in the second century AD because of its resem-
blance to a bunch of thyme flowers. It has two Thyroid Cartilage
lobes and lies in the upper part of the chest. The The largest cartilage in the LARYNX and forms
centre (cortex) resembles LYMPHOID TISSUE and the prominence of the Adams apple in front of
is made up of masses of small round cells called the neck.
thymocytes (see THYMOCYTE; LYMPHOCYTE).
The medulla is more loosely cellular and con- Thyroid Gland
sists of a stroma which contains far fewer A highly vascular organ situated in front of the
lymphocytes than are in the cortex. neck. It consists of a narrow isthmus crossing
The thymus gland is a vital part of the the windpipe close to its upper end, and joining
immunological system. Stem cells (see STEM together two lateral lobes which run upwards,
CELL) from the BONE MARROW come to the one on each side of the LARYNX. The gland is
thymus where they develop into immunologic- therefore shaped somewhat like a horseshoe,
ally competent cells. There are two distinct each lateral lobe being about 5 cm (2 inches)
populations of lymphocytes. One is dependent long and the isthmus about 12 mm ( inch)
on the presence of the thymus (T- wide, and it is firmly bound to the larynx. The
lymphocytes); the other is independent of the weight of the thyroid gland is about 285 grams
thymus (B-lymphocytes). Both are concerned (1 ounce), but it is larger in females than in
with immune responses (see IMMUNITY). The T- males and in some women increases in size dur-
lymphocyte is a cell which in the absence of ing MENSTRUATION. It often reaches an enor-
antigenic stimulation (see ANTIGEN) circulates mous size in the condition known as GOITRE
through the blood, lymph nodes and back into (see also THYROID GLAND, DISEASES OF).
the circulation again over a period of more than
ten years. It performs a policing role, awaiting Function The chief function of the thyroid
recognition of foreign material which it is able gland is to produce a hormone (see HORMONES)
to identify as such. It reacts by multiplication rich in iodine THYROXINE, which controls the
and transformation and these are the ingredi- rate of body METABOLISM. Thus, if it is
ents of the immune response. B-lymphocytes deficient in infants they fail to grow and suffer
are produced in the bone marrow and are con- LEARNING DISABILITY, a condition formerly
cerned with the production of the circulating known as CRETINISM. If the deficiency develops
humoral ANTIBODIES. in adult life, the individual becomes obese,
The most common clinical disorder associ- lethargic, and develops a coarse skin, a condi-
ated with abnormality of the thymus is MYAS- tion known as hypothyroidism (see under THY-
THENIA GRAVIS. Ten per cent of patients with ROID GLAND, DISEASES OF). Overactivity of the
myasthenia gravis will have a tumour of the thyroid, or hyperthyroidism, results in loss of
thymus, whilst the remainder will have weight, rapid heart action, anxiety, overactivity
inflammatory changes in the thymus called and increased appetite. (See THYROID GLAND,
thymitis. DISEASES OF Thyrotoxicosis.)
The production of the thyroid hormone is
Thyroid Cancer controlled by a hormone of the PITUITARY
A rare disease that accounts for around 1 per GLAND the thyrotrophic hormone.
cent of all cancers, cancer of the THYROID T
GLAND usually presents as an isolated hard Thyroid Gland, Diseases of
nodule in the neck. The rate at which the nod-
ule grows depends upon the patients age and Goitre
type of cancer cell. Pain is not usually a feature, SIMPLE GOITRE A benign enlargement of the
but the increasing size may result in the tumour THYROID GLAND with normal production of
pressing on vital structures in the neck for hormone. It is ENDEMIC in certain geographical
example, the nerves controlling the LARYNX areas where there is IODINE deficiency. Thus, if
(resulting in hoarseness) and the PHARYNX iodine intake is deficient, the production of
(causing difficulty in swallowing). If more than thyroid hormone is threatened and the anterior
one nodule is present, they are likely to be PITUITARY GLAND secretes increased amounts of
benign, not malignant. Treatment is by surgical thyrotrophic hormone with consequent over-
removal after which the patient will need to growth of the thyroid gland. Simple goitres in
take THYROXINE for the rest of his or her life. non-endemic areas may occur at puberty, dur-
Radioactive iodine is usually given after surgery ing pregnancy and at the menopause, which are
 710 Thyroid Gland, Diseases of

times of increased demand for thyroid hor- Treatment A symptomless goitre may grad-
mone. The only effective treament is thyroid ually disappear or be so small as not to merit
replacement therapy to suppress the enhanced treatment. If the goitre is large or is causing the
production of thyrotrophic hormone. The patient difficulty in swallowing or breathing, it
prevalence of endemic goitre can be, and has may need surgical removal by partial or total
been, reduced by the iodinisation of domestic thyroidectomy. If the patient is deficient in iod-
salt in many countries. ine, fish and iodised salt should be included in
NODULAR GOITRES do not respond as well as the diet.
the diffuse goitres to THYROXINE treatment.
They are usually the result of alternating epi- Hyperthyroidism is a common disorder
sodes of hyperplasia and involution which lead affecting 25 per cent of all females at some
to permanent thyroid enlargement. The only time in their lives. The most common cause
effective way of curing a nodular goitre is to around 75 per cent of cases is thyrotoxicosis
excise it, and THYROIDECTOMY should be (see below). An ADENOMA (or multiple aden-
recommended if the goitre is causing pressure omas) or nodules in the thyroid also cause
symptoms or if there is a suspicion of hyperthyroidism. There are several other rare
malignancy. causes, including inflammation caused by a
LYMPHADENOID GOITRES are due to the pro- virus, autoimune reactions and cancer. The
duction of ANTIBODIES against antigens (see symptoms of hyperthyroidism affect many of
ANTIGEN) in the thyroid gland. They are an the bodys systems as a consequence of the
example of an autoimmune disease. They tend much-increased metabolic rate.
to occur in the third and fourth decade and the Thyrotoxicosis is a syndrome consisting of
gland is much firmer than the softer gland of a diffuse goitre (enlarged thyroid gland), over-
simple goitre. Lymphadenoid goitres respond to activity of the gland and EXOPHTHALMOS (pro-
treatment with thyroxine. truding eyes). Patients lose weight and develop
TOXIC GOITRES may occur in thyrotoxicosis an increased appetite, heat intolerance and
(see below), although much less frequently sweating. They are anxious, irritable, hyper-
autonomous nodules of a nodular goitre may be active, suffer from TACHYCARDIA, breathless-
responsible for the increased production of thy- ness and muscle weakness and are sometimes
roxine and thus cause thyrotoxicosis. Thyro- depressed. The hyperthyroidism is due to the
toxicosis is also an autoimmune disease in production of ANTIBODIES to the TSH receptor
which an antibody is produced that stimulates (see THYROTROPHIN-STIMULATING HORMONE
the thyroid to produce excessive amounts of (TSH)) which stimulate the receptor with result-
hormone, making the patient thyrotoxic. ant production of excess thyroid hormones.
Rarely, an enlarged gland may be the result of The goitre is due to antibodies that stimulate
cancer in the thyroid. the growth of the thyroid gland. The exoph-

Anterior diagrammatic view showing positions of thymus (left) and thyroid (right) glands around the
trachea between the lungs.
 Thyroid Gland, Diseases of 711

thalmos is due to another immunoglobulin dence of hypothyroidism is much greater than

called the ophthalmopathic immunoglobulin, with other forms of treatment. However, the
which is an antibody to a retro-orbital antigen management of hypothyroidism is simple and
on the surface of the retro-orbital EYE muscles. requires thyroxine tablets and regular monitor-
This provokes inflammation in the retro-orbital ing for hypothyroidism. There is no evidence of
tissues which is associated with the accumula- any increased incidence of cancer of the thyroid
tion of water and mucopolysaccharide which or LEUKAEMIA following radio-iodine therapy.
fills the orbit and causes the eye to protrude It has been the pattern in Britain to reserve
forwards. radio-iodine treatment to those over the age of
Although thyrotoxicosis may affect any age- 35, or those whose prognosis is unlikely to be
group, the peak incidence is in the third decade. more than 30 years as a result of cardiac or
Females are affected ten times as often as males; respiratory disease. Radioactive iodine treat-
the prevalence in females is one in 500. As with ment should not be given to a seriously thyro-
many other autoimmune diseases, there is an toxic patient.
increased prevalence of autoimmune thyroid BETA-ADRENOCEPTOR-BLOCKING DRUGS Usu-
disease in the relatives of patients with thyro- ally PROPRANOLOL HYDROCHLORIDE: useful for
toxicosis. Some of these patients may have symptomatic treatment during the first 48
hypothyroidism (see below) and others, thyro- weeks until the longer-term drugs have reduced
toxicosis. Patients with thyrotoxicosis may pres- thyroid activity.
ent with a goitre or with the eye signs or, most
commonly, with the symptoms of excess thy- Hypothyroidism A condition resulting
roid hormone production. Thyroid hormone from underactivity of the thyroid gland. One
controls the metabolic rate of the body so that form, in which the skin and subcutaneous tis-
the symptoms of hyperthyroidism are those of sues thicken and result in a coarse appearance,
excess metabolism. is called myxoedema. The thyroid gland
The diagnosis of thyrotoxicosis is confirmed secretes two hormones thyroxine and tri-
by the measurement of the circulating levels of iodothyronine and these hormones are
the two thyroid hormones, thyroxine and TRI- responsible for the metabolic activity of the
IODOTHYRONINE. body. Hypothyroidism may result from devel-
opmental abnormalities of the gland, or from a
Treatment There are several effective treat- deficiency of the enzymes necessary for the syn-
ments for thyrotoxicosis. thesis of the hormones. It may be a feature of
ANTITHYROID DRUGS These drugs inhibit the endemic goitre and retarded development, but
iodination of tyrosine and hence the formation the most common cause of hypothyroidism is
of the thyroid hormones. The most commonly the autoimmune destruction of the thyroid
used drugs are carbimazole and propylthiouri- known as chronic thyroiditis. It may also occur
cil: these will control the excess production of as a result of radio-iodine treatment of thyroid
thyroid hormones in virtually all cases. Once overactivity (see above) and is occasionally sec-
the patients thyroid is functioning normally, ondary to pituitary disease in which inadequate
the dose can be reduced to a maintenance level TSH production occurs. It is a common dis-
and is usually continued for two years. The dis- order, occurring in 14 per 1,000 females and
advantage of antithyroid drugs is that after two one per 1,000 males. Most patients present
years treatment nearly half the patients will between the age of 30 and 60 years.
relapse and will then require more definitive T
therapy. Symptoms As thyroid hormones are respon-
PARTIAL THYROIDECTOMY Removal of three- sible for the metabolic rate of the body, hypo-
quarters of the thyroid gland is effective treat- thyroidism usually presents with a general slug-
ment of thyrotoxicosis. It is the treatment of gishness: this affects both physical and mental
choice in those patients with large goitres. The activities. The intellectual functions become
patient must however be treated with medica- slow, the speech deliberate and the formation of
tion so that they are euthyroid (have a normally ideas and the answers to questions take longer
functioning thyroid) before surgery is under- than in healthy people. Physical energy is
taken, or thyroid crisis and cardiac arrhythmias reduced and patients frequently complain of
may complicate the operation. lethargy and generalised muscle aches and
RADIOACTIVE IODINE THERAPY This has been pains. Patients become intolerant of the cold
in use for many years, and is an effective means and the skin becomes dry and swollen. The
of controlling hyperthyroidism. One of the dis- LARYNX also becomes swollen and gives rise to a
advantages of radioactive iodine is that the inci- hoarseness of the voice. Most patients gain
 712 Thyroidectomy

weight and develop constipation. The skin removed surgically or destroyed using radio-
becomes dry and yellow due to the presence of active iodine.
increased carotene. Hair becomes thinned and
brittle and even baldness may develop. Swelling Thyrotoxicosis A disorder of the thyroid
of the soft tissues may give rise to a CARPAL gland in which excessive amounts of thyroid
TUNNEL SYNDROME and middle-ear deafness. hormones are secreted into the bloodstream.
The diagnosis is confirmed by measuring the Resultant symptoms are tachycardia, tremor,
levels of thyroid hormones in the blood, which anxiety, sweating, increased appetite, weight
are low, and of the pituitary TSH which is loss and dislike of heat. (See hyperthyroidism
raised in primary hypothyroidism. above.)

Treatment consists of the administration of Thyroidectomy

thyroxine. Although tri-iodothyronine is the Surgical removal of the THYROID GLAND. Par-
metabolically active hormone, thyroxine is con- tial thyroidectomy removal of part of the
verted to tri-iodothyronine by the tissues of the gland is sometimes done in patients with
body. Treatment should be started cautiously hyperthyroidism (see under THYROID GLAND,
and slowly increased to 02 mg daily the DISEASES OF) when drug treatment has failed to
equivalent of the maximum output of the thy- control the disorder.
roid gland. If too large a dose is given initially,
palpitations and tachycardia are likely to result; Thyroiditis
in the elderly, heart failure may be precipitated. See under THYROID GLAND, DISEASES OF.

Congenital hypothyroidism Babies may Thyrotoxicosis

be born hypothyroid as a result of having little See under THYROID GLAND, DISEASES OF.
or no functioning thyroid-gland tissue. In the
developed world the condition is diagnosed by Thyrotrophin-Releasing
screening, all newborn babies having a blood Hormone (TRH)
test to analyse TSH levels. Those found positive A hormone (see HORMONES) produced and
have a repeat test and, if the diagnosis is con- released by the HYPOTHALAMUS which stimu-
firmed, start on thyroid replacement therapy lates the release of THYROTROPHIN-
within a few weeks of birth. As a result most of STIMULATING HORMONE (TSH) by the PITUIT-
the ill-effects of cretinism can be avoided and ARY GLAND.
the children lead normal lives.
Thyrotrophin-Stimulating
Thyroiditis Inflammation of the thyroid Hormone (TSH)
gland. The acute form is usually caused by a A hormone (see HORMONES) manufactured and
bacterial infection elsewhere in the body: released by the anterior part of the PITUITARY
treatment with antibiotics is needed. Occasion- GLAND which stimulates the THYROID GLAND
ally a virus may be the infectious agent. Hashi- to manufacture and release thyroid hormones
motos thyroiditis is an autoimmune disorder (THYROXINE and TRI-IODOTHYRONINE).
causing hypothyroidism (reduced activity of the
gland). Subacute thyroiditis is inflammation of Thyroxine
unknown cause in which the gland becomes (T4) A crystalline substance, containing IOD-
T painful and the patient suffers fever, weight loss INE, isolated from the THYROID GLAND and
and malaise. It sometimes lasts for several possessing the properties of thyroid extract. It
months but is usually self-limiting. has also been synthesised. It is used in patients
with defective function of the thyroid, such as
Thyrotoxic adenoma A variety of thyro- myxoedema (see THYROID GLAND, DISEASES OF
toxicosis (see hyperthyroidism above) in which Hypothyroidism).
one of the nodules of a multinodular goitre
becomes autonomous and secretes excess thy- TIA
roid hormone. The symptoms that result are See TRANSIENT ISCHAEMIC ATTACKS OR EPI-
similar to those of thyrotoxicosis, but there are SODES (TIA, TIE).
minor differences.
Tibia
Treatment The first line of treatment is to The larger of the two bones in the leg. One
render the patient euthyroid by treatment with surface of the tibia lies immediately beneath the
antithyroid drugs. Then the nodule should be skin in front, forming the shin; fractures of this
 Tinnitus 713

bone are usually compound ones. The thigh and HYPERTENSION. It is also used in the treat-
bone abuts on the larger upper end of the tibia ment of GLAUCOMA. (See also ADRENERGIC
at the knee-joint, whilst below, the tibia and RECEPTORS.)
fibula together enter into the ankle-joint, the
two bosses or malleoli at the ankle belonging, Tincture
the inner to the tibia, the outer to the fibula. An alcoholic solution used in PHARMACY, gen-
erally of some vegetable substance.
Tic
A repetitive, usually involuntary SPASM that var- Tinea
ies from being the simple twitch of a muscle See RINGWORM.
for example, affecting an eyelid to complex
coordinated actions. About 20 per cent of chil- Tinnitus
dren suffer from tic which normally lasts several A noise heard in the EAR without any external
months. Emotional stress is a common cause cause. It often accompanies DEAFNESS, and
(see GILLES DE LA TOURETTES SYNDROME). severely deaf patients find tinnitus as troubling
as if not more so than the deafness. Tinnitus
Tic Douloureux is described as objective if it is produced by
Another name for TRIGEMINAL NEURALGIA due sound generated within the body by vascular
to some affection of the fifth cranial nerve, and tumours or abnormal blood flows. In patients
characterised by pain situated somewhere with conductive hearing loss, tinnitus may be
about the temple, forehead, face, or jaw and the consequence of the blocking of outside
sometimes by SPASM in the muscles of the noises so that their own bodily activities
affected region. become audible. Even normal people occasion-
ally suffer from tinnitus, but rarely at a level
Ticks which prompts them to seek medical advice.
Ticks are blood-sucking arthropods which are Present knowledge of the neurophysiological
responsible for transmitting a wide range of dis- mechanisms is that the noise arises high in the
eases to humans, including ROCKY MOUNTAIN central nervous system in the subcortical
SPOTTED FEVER, African tick typhus, LYME DIS- regions of the BRAIN.
EASE and fivre boutonneuse (see TYPHUS The resting level of spontaneous neuronal
FEVER). Apart from being transmitters of dis- activity in the hearing system is only just below
ease, they cause intense itching and may cause that at which sound enters a persons con-
quite severe lesions of the skin. The best repel- sciousness a consequence of the fine-tuning of
lents are dimethyl phthalate and diethyltolu- normal hearing; so it is not, perhaps, surprising
amide. Once bitten, relief from the itching is that normally unheard neuronal activity
obtained from the application of calamine becomes audible. If a patient suffers sen-
lotion. Tick-bites are an occupational hazard of sorineural deafness, the body may reset the
shepherds and gamekeepers. (See also BITES AND awareness threshold of neural activity, with the
STINGS.) brain attempting greater sensitivity in an effort
to overcome the deafness. The condition has a
Ticlopidine strong emotional element and its management
A recently introduced antiplatelet drug, which calls for a psychological approach to help suf-
decreases clumping of blood PLATELETS and ferers cope with what are, in effect, physically
thus inhibits the formation of clots (see BLOOD untreatable symptoms. They should be T
CLOT; THROMBUS). It is used to prevent epi- reassured that tinnitus is not a signal of an
sodes in patients with a history of symptomatic impending stroke or of a disorder of the brain.
ischaemic disease such as STROKE and INTER- COGNITIVE BEHAVIOUR THERAPY can be valu-
MITTENT CLAUDICATION. The drug should be able in coping with the unwanted noise. Trad-
started under hospital supervision. itionally, masking sounds, generated by an
electrical device in the ear, were used to help
TIE tinnitus sufferers by, in effect, making the tin-
See TRANSIENT ISCHAEMIC ATTACKS OR EPI- nitus inaudible. Even with the introduction of
SODES (TIA, TIE). psychological retraining treatment, these mask-
ers may still be helpful; the masking-noise vol-
Timolol Maleate ume, however, should be kept as low as pos-
A beta-adrenoceptor-blocking drug which is of sible or it will interfere with the retraining pro-
value in the treatment of ANGINA PECTORIS, cess. For patients with very troublesome tin-
myocardial infarction (see HEART, DISEASES OF) nitus, lengthy counselling and retraining
 714 Tissue Plasminogen Activator (TPA, tPA)

courses may be required. Surgery is not system (see IMMUNITY) will reject the donors
recommended. organ. The main factors that are relevant to an
Under the auspices of the Royal National individuals reaction to donor tissue are called
Institute for Deaf People, the RNID Tinnitus histocompatability antigens (see ANTIGEN).
Helpline has been established. Calls are charged These are mostly human leucocyte antigens
at local rates. (See also MENIRES DISEASE.) (HLAs see HLA SYSTEM) present on the surface
of cells. HLAs are inherited and, like finger-
Tissue Plasminogen Activator prints, unique to an individual, although iden-
(TPA, tPA) tical twins have identical HLAs and hence are
A natural PROTEIN that occurs in the body. It perfect matches for TRANSPLANTATION
has the property of breaking down a THROM- procedures.
BUS in a blood vessel (see THROMBOLYSIS). It is
effective only in the presence of FIBRIN and Titration
activates plasminogen, which occurs normally A form of chemical analysis by standard solu-
on the surface of the fibrin. TPA is an import- tions of known strength.
ant thrombolytic treatment immediately after a
myocardial infarction (see HEART, DISEASES OF). Titre
The strength of a solution as determined by
Tissues of the Body TITRATION. In medicine it is used to describe
The simple elements from which the various the amount of antibody (see ANTIBODIES)
parts and organs are found to be built. All the present in a known volume of SERUM.
body originates from the union of a pair of
CELLS, but as growth proceeds the new cells
Titubation
produced from these form tissues of varying A regular nodding movement of the head that
character and complexity. It is customary to div- sometimes involves the trunk. The term can
ide the tissues into five groups: also refer to a staggering or reeling condition,
Epithelial tissues, including the cells covering especially due to disease of the SPINAL CORD or
the skin, those lining the alimentary canal, cerebellum (see BRAIN).
those forming the secretions of internal
organs. (See EPITHELIUM.)
Tizanidine
Connective tissues, including fibrous tissue,
fat, bone, cartilage. (See under these headings.)
A recently introduced skeletal-muscle relaxant
used in patients whose muscle spasticity is
Muscular tissues (see MUSCLE).
associated with MULTIPLE SCLEROSIS (MS) or
Nervous tissues (see NERVE).
injury to the SPINAL CORD. Its side-effects
Wandering corpuscles of the BLOOD and
LYMPH.
include drowsiness, tiredness, dizziness, dry
mouth, nausea and lowered blood pressure.
Many of the organs are formed of a single
one of these tissues, or of one with a very slight
admixture of another, such as cartilage, or white T-Lymphocyte
fibrous tissue. Other parts of the body that are See LYMPHOCYTE.
widely distributed are very simple in structure
and consist of two or more simple tissues in TNM Classification
varying proportion. Such are blood vessels (see A method of classifying cancers to determine
T ARTERIES; VEINS), lymphatic vessels (see LYM- how far they have spread. This helps doctors to
PHATICS), lymphatic glands (see GLAND), SER- determine the best course of treatment and the
OUS MEMBRANES, synovial membranes (see prognosis; it is also useful in research. Origin-
JOINTS), mucous membranes (see MUCOUS ally defined by the American Joint Committee
MEMBRANE), secreting glands (see GLAND; SAL- on Cancer, the T applies to the primary
IVARY GLANDS; THYROID GLAND) and SKIN. tumour, the N to any lymph-node involve-
The structure of the more complex organs of ment, and the M to any metastatic spread. (See
the body is dealt with under the heading of each CANCER; METASTASIS; TUMOUR; LYMPH
organ. NODES.)

Tissue Typing Tobacco

The essential procedure for matching the tissue The leaf of several species of nicotiana, espe-
of a recipient in need of transplanted tissue or cially of the American plant Nicotiana tabacum.
organ to that of a potential donor. Unless there The smoking of tobacco is the most serious
is a reasonable match, the recipients immune public-health hazard in Britain today. It causes
 Tomography 715

100,000 premature deaths a year in the United stance for which there are no effective prevent-
Kingdom alone. In addition to the deaths ive measures except the willpower of the indi-
caused by cigarette smoking, it is also a major vidual smoker or non-smoker. (Escalating tax-
cause of disability and illness in the form of ation of tobacco seems to have been circum-
myocardial infarction (see HEART, DISEASES OF), vented as a deterrent by the rising incidence of
PERIPHERAL VASCULAR DISEASE, and EMPHY- smuggling cigarettes into Britain.)
SEMA. Tobacco-smoking is also a serious hazard Action on Smoking and Health (ASH) is a
to the FETUS if the mother smokes. Further- small charity founded by the Royal College of
more, passive smoking inhalation of other Physicians in 1971 that attempts to alert and
peoples tobacco smoke has been shown to be inform the public to the dangers of smoking
a health hazard to non-smokers. and to try to prevent the disability and death
which it causes.
Composition In addition to vegetable fibre,
tobacco leaves contain a large quantity of ash, Tobramycin
the nature of this depending predominantly An aminoglycoside antibiotic used to treat ser-
upon the minerals present in the ground where ious infections such as MENINGITIS and PERI-
the tobacco plant has been grown. Of the TONITIS as well as those affecting bones, joints
organic constituents, the brown fluid alkaloid and lungs. It is given by injection, sometimes in
known as NICOTINE is the most important. The conjunction with penicillin. It has a range of
nicotine content of different tobacco varies, and side-effects including damage to the balance and
the amount absorbed depends upon whether or hearing mechanisms as well as to the kidney.
not the smoker inhales. Nicotine is the sub-
stance that causes a person to become addicted Toes
to tobacco smoking (see DEPENDENCE). See CORNS AND BUNIONS; SKIN Nail.
Tobacco smoke also contains some 16 sub-
stances capable of inducing cancer in experi- Tolazomide
mental animals. One of the most important of See SULPHONYLUREAS.
these is benzpyrene, a strongly carcinogenic
hydrocarbon. As this is present in coal tar pitch, Tolbutamide
it is commonly referred to in this context as tar. A sulphonamide derivative, or sulphonylurea
Other constituents of tobacco smoke include (see SULPHONYLUREAS), which lowers the level
pyridine, ammonia and carbon monoxide. of the blood sugar in DIABETES MELLITUS. As it
Nicotine addiction is a life-threatening but is rapidly excreted from the body, it has to be
treatable disorder, and nicotine-replacement taken twice daily. Like CHLORPROPAMIDE, it
treatment is available on NHS prescription. may induce undue sensitivity to alcohol.
This includes the provision of bupropion
trade name Zyban. The availability of this Tolerance
drug which should be used with caution as it This occurs when the response to a particular
has unwelcome side-effects in some people amount of a drug or physiological messenger
and the introduction of specialist smoking- decreases, so that a larger dose must be given to
cessation services to provide behavioural sup- produce the same response as before. It is par-
port to people who wish to stop smoking ticularly common with certain drug dependen-
should result in a reduction in tobacco-related cies (see DEPENDENCE): for example, with MOR-
diseases. Given the critical position of nicotine PHINE or HEROIN. T
in leading people to become addicted to smok-
ing, it is anomalous that there are no effective Toluene
government regulations covering the sales of Also called methylbenzene: a product of the
tobacco. Because it is not a food, tobacco is not distillation of coal tar widely used as a solvent in
regulated by the Food Standards Agency; it is the manufacture of paint and rubber and plastic
not classified as a drug so is not controlled by cements.
legislation on medicines. Furthermore, despite
being a consumer product, tobacco is exempt Tomography
from the Consumer Protection Act (1987) and A technique using X-RAYS or ULTRASOUND to
other government safety regulations. So the build up a focused image of a slice through the
NHS is left to try to ameliorate the serious body at a given level. By producing a series of
health consequences lung cancer, cardio- such slices at different depths, a three-
vascular disease, peripheral vascular disease, dimensional image of the body structures can
chronic bronchitis, and emphysema of a sub- be built up.
 716 -tomy

-tomy tongue from the mouth; other muscles, which

A suffix indicating an operation by cutting. retract the tongue, attach it to the hyoid bone,
the larynx, the PALATE, and the styloid process
Tongue on the base of the SKULL.
The tongue is made up of several muscles, is The mucous membrane on the under-
richly supplied with blood vessels and nerves, surface of the tongue is very thin. In the mid-
and is covered by highly specialised MUCOUS dle line, a fold of mucous membrane, the fre-
MEMBRANE. It consists of a free part known as num, passes from the under-surface to the
the tip, a body, and a hinder fixed part or root. floor of the mouth; when this frenum is
The under-surface lies upon the floor of the attached too far forwards towards the tip of the
mouth, whilst the upper surface is curved from tongue, the movements of the organ are
side to side, and still more from before back- impeded the condition being known as
wards so as to adapt it to the roof of the mouth. tongue-tie. On the upper surface or dorsum of
At its root, the tongue is in contact with, and the tongue, the mucous membrane is thicker,
firmly united to, the upper edge of the LARYNX; and in its front two-thirds is studded with pro-
so that in some persons who can depress the jections or papillae, most of which are conical.
tongue readily the tip of the EPIGLOTTIS may be Some of them end in long filaments, and are
seen projecting upwards at its hinder part. then known as filiform papillae. On the tip,
and towards the edges of the tongue, small,
Structure The substance of the tongue con- red, rounded fungiform papillae are seen,
sists almost entirely of muscles running in vari- which act as end-organs for the sense of taste
ous directions. The tongue also has numerous as do circumvallate papillae, each of which is
outside attachments: one muscle on each side surrounded by a trench along which open
unites it to the lower jaw-bone just behind the numerous taste-buds. These taste-buds are also
chin, and this muscle serves to protrude the found in the fungiform papillae, scattered over

(Left) Tongue from above showing different areas of taste discrimination. (Right) Vertical section through
surface of tongue showing taste-bud ( x 400).
 Tonsillitis 717

the throat, FAUCES, and palate. Five nerves, truded may be seen in various neurological dis-
originating from the fifth, seventh, ninth, eases, but may be caused by alcoholism.
tenth and 12th cervical nerves supply the After a STROKE involving the motor nerve
tongue. centre, the control of one side of the tongue
musculature will be lost. This will result in
Functions The chief uses of the tongue are: the protruded tongue pointing to the side of
tomastication,
push the food between the teeth for
and then mould it into a bolus
the body which is paralysed. The sense of
taste on one side of the tongue may also be
preparatory to swallowing; lost in some diseases of the brain and facial
asorgan
the organ of the sense of taste, and as an
provided with a delicate sense of
nerve.
The presence of fur on the tongue may be
touch; and obvious and distressing. This is due to thicken-
to(Seeplay a part in the production of speech.
VOICE AND SPEECH.)
ing of the superficial layers of the tongue which
may appear like hairs which trap food debris
It is usual to classify any taste as: sweet, bitter, and become discoloured. Furring is common
salt and acid, since finer distinctions are largely during fever and as a result of mouth-breathing
dependent upon the sense of smell. The loss of and smoking.
keenness in taste brought about by a cold in the In some conditions the tongue may appear
head, or even by holding the nose while swal- dry, red and raw (GLOSSITIS). An inflamed beefy
lowing, is well known. Sweet tastes seem to be tongue is characteristic of pellagra, a disease
best appreciated by the tip of the tongue, acids caused by deficiency of NICOTINIC ACID in the
on its edges, and bitters at the back. There are diet. A magenta-coloured tongue may be seen
probably different nerve-fibres and end-organs when there is a lack of RIBOFLAVIN.
for the different varieties of taste. Many tastes
depend upon the ordinary sensations of the Ulcers of the tongue are similar to those
tongue. elsewhere in the mouth. The most common are
Like other sensations, taste can be very aphthous ulcers which are small, red and pain-
highly educated for a time, as in tea-tasters and ful and last for about ten days. They are associ-
wine-tasters, but this special adaptation is lost ated with stress, mild trauma (such as from
after some years. jagged teeth), and occasionally with folic acid
and vitamin B12 deficiency. Ulcers of the tongue
Tongue, Disorders of are sometimes found in patients with chronic
bowel disease.
Conditions of the tongue At rest, the
TONGUE touches all the lower teeth and is Tonics
slightly arched from side to side. It has a These are placebos (see PLACEBO) and may be
smooth surface with a groove in the middle and used in conditions for which there is no known
an even but definite edge. It is under voluntary remedy, to strengthen and support the patient.
control and the tip can be moved in all Available tonics range from rhubarb compound
directions. mixture to various mineral and vitamin
Ankyloglossia or tongue-tie is a rare disorder supplements.
in which the frenum or band connecting the
lower surface of the tongue to the floor of the Tonsillitis
mouth is so short or tight that the tongue can- Tonsillitis is the inflammation of the TONSILS. T
not be protruded. Surgery can remedy the The disorder may be the precurosor of a virus-
defect. It is easy to overdiagnose and is not a induced infection of the upper respiratory tract
common cause of difficulty in feeding at birth such as the COMMON COLD, INFLUENZA or
or speech defects in infancy. infectious MONONUCLEOSIS, in which case the
Gross enlargement of the tongue can make inflammation usually subsides as other symp-
speech indistinct or make swallowing and even toms develop. Such virus-induced tonsillitis
breathing difficult. This is known as macroglos- does not respond to treatment with antibiotics.
sia and may be such that the tongue is con- This section describes tonsillitis caused by bac-
stantly protruded from the mouth. The cause terial infection.
may be CONGENITAL, as in severe cases of
DOWNS (DOWN) SYNDROME, or it may occur as Acute tonsillitis The infection is never
a result of ACROMEGALY or be due to abnormal entirely confined to the tonsils; there is always
deposits as in AMYLOIDOSIS. some involvement of the surrounding throat or
A marked tremor of the tongue when pro- pharynx. The converse is true that in many
 718 Tonsils

cases of sore throat, the tonsils are involved in loose connective tissue containing lymph cor-
the generalised inflammation of the throat. puscles in its meshes, and packed here and there
into denser nodules or follicles. The tonsils play
Causes Most commonly caused by the - an important role in the protective mechanism
haemolytic STREPTOCOCCUS, its incidence is of the body against infection.
highest in the winter months. In the developing
world it may be the presenting feature of DIPH- Tooth
THERIA, a disease now virtually non-existant in See TEETH.
the West since the introduction of
IMMUNISATION. Tooth, Supernumerary
Malformed extra TEETH are frequently found,
Symptoms The onset is usually fairly sudden particularly in the upper incisor region. They
with pain on swallowing, fever and malaise. On often do not erupt, but prevent the eruption of
examination, the tonsils are engorged and the permanent teeth.
covered with a whitish discharge (PUS). This
may occur at scattered areas over the tonsillar Toothache
crypts (follicular tonsillitis), or it may be more See TEETH, DISORDERS OF.
extensive. The glands under the jaw are
enlarged and tender, and there may be pain in Tophus
the ear on the affected side: although usually The name given to urate-based deposits which
referred pain, this may indicate spread of the form in connection with joints or tendon
infection up the Eustachian tube to the ear, par- sheaths as the result of attacks of GOUT. At first
ticularly in children. Occasionally an ABSCESS, the tophus is a soft mass, but later becomes
or quinsy, develops around the affected tonsil. quite hard. It is composed of biurate of soda.
Due to a collection of pus, it usually comes on
four to five days after the onset of the disease, Topical
and requires specialist surgical treatment. Pertaining to drugs or other treatment applied
locally to the area being treated e.g. the skin,
Treatment Most cases need no treatment. eye, etc.
Therefore, it is advisable to take a throat swab
to assess the nature of any bacterial treatment Torasemide
before starting treatment. Penicillin or eryth- A loop diuretic (see DIURETICS) used in the
romycin are the drugs of choice where beta- treatment of OEDEMA and HYPERTENSION.
haemolytic streptococci are isolated, together
with paracetamol or aspirin, and plenty of Torpor
fluids. Removal of tonsils is indicated: when the A condition of bodily and mental inactivity, not
tonsils and adenoids are permanently so amounting to sleep, but interfering greatly with
enlarged as to interfere with breathing (in such the ordinary habits and pursuits. It is often
cases the adenoids are removed as well as the found in people suffering from fever, and is
tonsils); when the individual is subject to recur- a common symptom in aged people whose
rent attacks of acute tonsillitis which are caus- arteries are diseased.
ing significant debility, absence from school or
work on a regular basis (more than four times a Torsion
T year); when there is evidence of a tumour of Twisting. The term is applied to the process in
the tonsil. Recurrent sore throat is not an which organs, or tumours, which are attached
indication for removing tonsils. to the rest of the body by a narrow neck or
pedicle, become twisted so as to narrow the
Tonsils blood vessels or other structures in the pedicle.
Two almond-shaped glands (see GLAND) situ- (See TESTICLE, DISEASES OF.)
ated one on each side of the narrow FAUCES Torsion is also the term applied to the twist-
where the mouth joins the throat. Each has a ing of the small arteries severed at an operation,
structure resembling that of a lymphatic gland, by which bleeding from them is stopped.
and consists of an elevation of the mucous
membrane presenting 1215 openings, which Torticollis
lead into pits or lacunae. The mucous covering This is shortness of the sternomastoid muscle
is formed by the ordinary mucous membrane of on one side, resulting in asymmetry and limita-
the mouth, which also lines the pits; and the tion of movement of the neck. (See SPASMODIC
main substance of the gland is composed of TORTICOLLIS; WRY-NECK.)
 Touch 719

Touch ated by only 1 mm; on the tips of the fingers

The sense that enables an individual to assess they must be separated to twice that distance,
the physical characteristics of objects for whilst on the arm or leg they cannot be felt as
example, their size, shape, temperature and tex- two points unless separated by over 25 mm, and
ture. The sense of touch is considered here on the back they must be separated by more
along with other senses associated with the skin than 50 mm. On the parts covered by hair, the
and muscles. The cutaneous senses comprise: nerves ending around the roots of the hairs also
take up impressions of touch.
Touch sense proper, by which we per- Pressure is estimated probably through the
ceive a touch or stroke and estimate the size and same nerve-endings and nerves that have to do
shape of bodies with which we come into con- with touch, but it depends upon a difference in
tact, but which we do not see. the sensations of parts pressed on and those of
surrounding parts. Heat-sense, cold-sense and
Pressure sense, by which we judge the pain-sense all depend upon different nerve-
heaviness of weights laid upon the skin, or endings in the skin; by using various tests, the
appreciate the hardness of objects by pressing skin may be mapped out into a mosaic of little
against them. areas where the different kinds of impressions
are registered. Whilst the tongue and finger-tips
Heat sense, by which we perceive that an are the parts most sensitive to touch, they are
object is warmer than the skin. comparatively insensitive to heat, and can easily
bear temperatures which the cheek or elbow
Cold sense, by which we perceive that an could not tolerate. The muscular sense depends
object touching the skin is cold. upon the sensory organs known as muscle-
spindles, which are scattered through the sub-
Pain sense, by which we appreciate pricks, stance of the muscles, and the sense of locality is
pinches and other painful impressions. dependent partly upon these and partly upon
the nerves which end in tendons, ligaments and
Muscular sensitiveness, by which the joints.
painfulness of a squeeze is perceived. It is pro-
duced probably by direct pressure upon the Disorders of the sense of touch occur in
nerve-fibres in the muscles. various diseases.
HYPERAESTHESIA is a condition in which there
Muscular sense, by which we test the is excessive sensitiveness to any stimulus, such
weight of an object held in the hand, or gauge as touch. When this reaches the stage when a
the amount of energy expended on an effort. mere touch or gentle handling causes acute
pain, it is known as hyperalgesia. It is found in
Sense of locality, by which we can, with- various diseases of the SPINAL CORD immedi-
out looking, tell the position and attitude of ately above the level of the disease, combined
any part of the body. often with loss of sensation below the diseased
part. It is also present in NEURALGIA, the skin of
Common sensation, which is a vague the neuralgic area becoming excessively tender
term used to mean composite sensations pro- to touch, heat or cold. Heightened sensibility to
duced by several of the foregoing, like tickling, temperature is a common symptom of
or creeping, and the vague sense of well-being NEURITIS. T
or the reverse that the mind receives from ANAESTHESIA, or diminution of the sense of
internal organs. (See the entry on PAIN.) touch, causing often a feeling of numbness, is
The structure of the end-organs situated in present in many diseases affecting the nerves of
the skin, which receive impressions from the sensation or their continuations up the pos-
outer world, and of the nerve-fibres which con- terior part of the spinal cord. The condition of
duct these impressions to the central nervous dissociated analgesia, in which a touch is quite
system, have been described under NERVOUS well felt, although there is complete insens-
SYSTEM. (See also SKIN.) ibility to pain, is present in the disease of the
Touch affects the Meissners or touch cor- spinal cord known as SYRINGOMYELIA, and
puscles placed beneath the epidermis; as these affords a proof that the nerve-fibres for pain and
differ in closeness in different parts of the skin, those for touch are quite separate. In tabes dor-
the delicacy of the sense of touch varies greatly. salis (see SYPHILIS) there is sometimes loss of the
Thus the points of a pair of compasses can be sense of touch on feet or arms; but in other
felt as two on the tip of the tongue when separ- cases of this disease there is no loss of the sense
 720 Tourettes Syndrome

of touch, although there is a complete loss of rash. It is frequently associated with the use of
the sense of locality in the lower limbs, thus tampons (see TAMPON), but has occasionally
proving that these two senses are quite distinct. been reported in men. The syndrome may also
PARAESTHESIAE are abnormal sensations such as be linked to the use of contraceptives such as
creeping, tingling, pricking or hot flushes. the diaphragm, cap and sponge (see under CON-
TRACEPTION), and skin wounds or infections
Tourettes Syndrome may also be a cause. The disease is due to a
See GILLES DE LA TOURETTES SYNDROME. staphylococcal toxin (see STAPHYLOCOCCUS;
TOXINS). Treatment consists of supportive
Tourniquet measures to combat shock and eradication of
A device usually a rubber cord or tight ban- the staphylococcus by ANTIBIOTICS. The design
dage that is bound around a limb to stop of tampons has been improved. Recurrence of
temporarily the arterial blood supply and so the disorder has been reported and women who
control severe bleeding. Tourniquets should be have had an episode should stop using tampons
applied with caution; unless untied within 15 and vaginal contraceptives.
minutes, GANGRENE may result, necessitating
AMPUTATION. Because of this serious hazard, Toxins
they are rarely used nowadays; direct pressure Poisons produced by BACTERIA. (See also IMMUN-
on the bleeding points is simpler, safer and ITY; IMMUNOLOGY; MICROBIOLOGY.) Toxins
equally effective in emergencies. A temporary are usually soluble, easily destroyed by heat,
tourniquet to an arm to increase the distension sometimes of the nature of crystalline sub-
of veins when taking a sample of blood does no stances, and sometimes ALBUMINS. When
harm. injected into animals in carefully graduated
doses, they bring about the formation of sub-
Toxaemia stances called antitoxins which neutralise the
A term applied to forms of blood-poisoning action of the toxin. These antitoxins are gener-
due to the absorption of bacterial products ally produced in excessive amount, and the
(TOXINS) formed at some local site of infection, SERUM of the animal when withdrawn can be
such as an ABSCESS. In other cases the toxaemia used for conferring antitoxic powers upon other
is due to defective action of some excretory animals or human beings to neutralise the dis-
organ, such as the kidney (see KIDNEYS). As ease in question. The best known of these anti-
regards treatment, the most important con- toxins are those of DIPHTHERIA and TETANUS.
sideration is to remove the source of infection. Toxins are also found in many plants and in
Toxaemia of pregnancy is a term sometimes snake venom.
used to describe the two complications of preg- Some toxins are not set free by bacteria, but
nancy known as PRE-ECLAMPSIA and ECLAMPSIA remain in the substance of the latter. They are
(see also PREGNANCY AND LABOUR). known as endotoxins and are not capable of
producing antitoxins.
Toxbase
This the main toxicology database of the Toxocariasis
National Poisons Information Service (see POI- A disease acquired by swallowing the ova (eggs)
SONS). It is available on the Internet of a roundworm which lives in the intestine of
(www.spib.axl.co.uk). Toxbase gives informa- cats (Toxocara cati) or dogs (Toxocara canis). In
T tion about routine diagnosis, treatment and humans, the small larval worms produced by
management of people exposed to drugs, these ova migrate to various parts of the body,
household products and industrial and agri- including the retina of the EYE, where they then
cultural chemicals. Further information is die, producing a small GRANULOMA which in
available on 0131 536 2298. turn may produce allergic reactions. In the eye
it may cause choroidretinitis. It is said that 2 per
Toxic cent of apparently healthy people in Britain
Poisonous or likely to be lethal. have been infected in this way. A course of
treatment with thiabendazole is recommended,
Toxicology though the drug has side-effects and should be
The science dealing with POISONS. used with caution in the elderly.

Toxic Shock Syndrome Toxoid

First described in 1978, this disorder is charac- A toxin (see TOXINS) which has been rendered
terised by high fever, diarrhoea, SHOCK and a non-toxic by certain chemicals, or by heat, or
 Tracheostomy 721

by being partly neutralised by antitoxin. The compounds labelled with RADIONUCLIDE

best-known example is DIPHTHERIA toxoid. (See which give off radiation. This can be measured
also IMMUNITY.) with a gamma camera or a scintigram. The
information is used in the investigation of sus-
Toxoplasmosis pected tumours in the BRAIN or malfunctioning
Toxoplasmosis is a disease due to infection with of the THYROID GLAND.
protozoa of the genus Toxoplasma. The infec-
tion may be acquired from eating raw or under- Trachea
cooked meat, from cats, or from gardening or Popularly known as the windpipe, this tube
playing in contaminated soil. It occurs in two extends from the LARYNX above to the point in
forms: an acquired form, and a congenital the upper part of the chest, where it divides into
form. The acquired form may run such a the two large bronchial tubes, one to each lung
benign course that it is not recognised, the (see LUNGS). It is about 10 cm (4 inches) in
patient scarcely feeling ill. In the congenital length and consists of a fibrous tube kept per-
form the unborn child is infected by the manently open by about 20 strong, horizontally
mother. The congenital form, the incidence of placed hoops of cartilage, each of which forms
which in the United Kingdom is one in 5,000 about two-thirds of a circle, the two ends being
pregnancies (one in 2,000 pregnancies in Scot- joined behind by muscle-fibres. This fibrocarti-
land), may develop in one of two ways. The laginous tube is lined by a smooth mucous
infant may either appear generally ill, or the membrane, richly supplied with mucous
brunt of the infection may fall on the nervous glands and covered by a single layer of ciliated
system causing HYDROCEPHALUS, mental epithelium. (See also AIR PASSAGES.)
retardation, or loss of sight. In some cases the
infection may be so severe that it kills the fetus, Tracheitis
resulting in a miscarriage or stillbirth. In other Inflammation of the TRACHEA. It may occur
cases the infection is so mild that it is missed along with BRONCHITIS, or independently, due
until, in later life, the child begins to show signs to similar causes. Usually a viral condition,
of eye trouble. As the congenital form of the treatment may be unnecessary (see CROUP). A
disease, which is most serious, seems to develop rare condition, bacterial tracheitis, is more dan-
only if the mother acquires the infection during gerous as the patient produces large amount of
pregnancy, it would appear to be a wise precau- thick, sticky SPUTUM which may block the air-
tion that pregnant women should avoid contact way causing respiratory failure and collapse.
with cats and eating raw or undercooked meat Treatment is by insertion of an endotracheal
foods. tube under general anaesthesia (see ENDOTRA-
CHEAL INTUBATION), removing the secretions
tPA/TPA and using high-dose antibiotics.
See TISSUE PLASMINOGEN ACTIVATOR (TPA, tPA).
Tracheostomy
Trabecula Also known as tracheotomy. The operation in
(1) Thin strips of bony tissue occurring in can- which the TRACHEA or windpipe is opened
cellous BONE sometimes called spongy bone. from the front of the neck, so that air may be
(2) A band of CONNECTIVE TISSUE passing directly drawn or passed into the lower AIR PAS-
from the outer part of an organ to the interior, SAGES. The opening is made through the sec-
separating the organ into discrete chambers. ond and third rings of the trachea. T
Trace Elements Reasons for operation The cause of
Chemical elements that are distributed laryngeal obstruction should be treated but, if
throughout the tissues of the body in very small obstruction is acute and endangering the
amounts and are essential for the nutrition of patients life, urgent intervention is necessary.
the body. Nine such elements are now recog- In most cases the insertion of an endotracheal
nised: cobalt, copper, fluorine, iodine, iron, tube either through the nose or mouth and
manganese, molybdenum, selenium and zinc. down the pharynx through the larynx to bypass
the obstruction is effective (see ENDOTRACHEAL
Tracer INTUBATION). If not, tracheostomy is per-
A compound introduced into the body, the formed. The majority of tracheostomies
progress of which can subsequently be followed performed nowadays are for patients in
and information obtained about the bodys intensive-therapy-unit situations. These
metabolic activities. Radioactive tracers are patients require airway intervention for
 722 Trachoma

prolonged periods to facilitate artificial ventila- ally inactive. The bacterium is transmitted by
tion which is performed by means of a mechan- flies and causes inflammation of the con-
ical ventilator. The presence of a tube passing junctiva and cornea (see EYE) with consequent
through the larynx for a prolonged period of scarring. The active disease is treated with tetra-
time is associated with long-term damage to the cycline tablets and eye drops; cure is usually
larynx, and therefore any patients requiring pro- satisfactory. In theory, trachoma should be easy
longed intubation usually undergo a trache- to eliminate. The World Health Organisation,
ostomy to prevent further damage. Endotra- which aims to do this by 2020, is using a four-
cheal intubation is also the preferred method of pronged strategy to tackle the disease. This
airway-intervention for acute inflammatory comprises:
disorders of the upper airway (as opposed to
tracheostomy); tracheostomy in these cases is
surgery to correct deformed eyelids before
blindness occurs.
performed only in the emergency situation if antibiotics to kill Chlamydia.
facilities for endotracheal intubation are not regular face-washing to stop bacterial spread.
available or if they are unsuccessful. Trache-
ostomy may also be performed for large
environmental improvements for example,
better sanitation and rubbish disposal to
tumours which obstruct the larynx until some eliminate the bacteria.
form of treatment is instituted. Similarly it may
be needed in conditions whereby the nerve Traction
supply to the larynx has been jeopardised, The application of a pulling force to the distal
impairing its protective function of the upper part of a fracture in order to allow the fracture
airway and its respiratory function. to heal with the bone in correct alignment.
There are many different methods for apply-
Tracheostomy tubes When the trachea ing traction, usually involving weights and
has been opened by an incision through the pulleys.
skin between the Adams apple and the clav-
icles; another through the THYROID GLAND fol- Tractotomy
lowed by a small vertical incision in the trachea A neurological operation to relieve intractable
a metal or plastic tube is inserted to maintain PAIN. The thalamic tracts of the SPINAL CORD
the opening. There is always an outer tube contain the nerve-fibres that signal pain. They
which is fixed in position by tapes passing travel from the source of the pain in an organ
round the neck, and an inner tube which slides or tissue such as skin or bone via the cord to
freely out of and into the other, so that it may the brain stem and cortex (see BRAIN) where the
be removed at any time for cleansing, and is individual becomes conscious of the pain. The
readily coughed-out should it happen to operation aims to sever these tracts within the
become blocked by mucus. medulla oblongata of the brain.

After-treatment When the operation has Training

been performed for some permanent obstruc- See DIET; EXERCISE.
tion, the tube must be worn permanently; and
the double metal tube is in such cases replaced Trance
after a short time by a soft plastic single one. A profound SLEEP from which a person cannot
When the operation has relieved some obstruc- for a time be aroused, but which is not due to
T tion caused, say, by diphtheria, the tube is left organic disease. The power of voluntary move-
out now and then for a few hours, and finally, at ment is lost, although sensibility and even con-
the end of a week or so, is removed altogether, sciousness may remain. It is a disturbance in
after which the wound quickly heals up. mental functions and may be associated with
CATALEPSY, AUTOMATISM and petit mal EPI-
Trachoma LEPSY. A trance may be induced by HYPNOTISM.
Trachoma is a severe type of conjunctivitis (see (See also ECSTASY).
under EYE, DISORDERS OF). This chronic con-
tagious condition is caused by Chlamydia tra- Tranexamic Acid
chomatis, a bacterium with virus-like character- A drug used in the control of bleeding. It
istics. The disease affects 150 million people inhibits the activation of PLASMINOGEN and
worldwide and is common in developing coun- FIBRINOLYSIS, and may be useful when bleeding
tries, where it is the leading cause of preventable cannot be stopped for instance, dental extrac-
blindness. It may be seen in immigrant popula- tion in HAEMOPHILIA. The drug is also useful in
tions in developed countries, although it is usu- MENORRHAGIA.
 Transfusion 723

Tranquillisers which the operator can visualise the inside of

A tranquilliser is a popular name for a drug the uterus. The operation is done to treat MEN-
which induces a mental state free from agitation ORRHAGIA (heavy blood loss during MENSTRU-
and anxiety, and renders the patient calm. ATION) and its introduction has reduced the
Tranquillisers are classified as major and minor. need to perform HYSTERECTOMY for the
The former are used to treat psychotic illness condition.
such as SCHIZOPHRENIA; the latter are sedatives
used to treat anxiety and emotional upsets (see Transcutaneous Electrical Nerve
NEUROSIS) and are called antianxiety drugs or Stimulation (TENS)
ANXIOLYTICS. Major tranquillisers or antipsy- A method of electrical stimulation that is being
chotic drugs are given to patients with psych- used for the relief of PAIN, including that of
otic disorders which disrupt their normal lives MIGRAINE, NEURALGIA and phantom limbs (see
(see PSYCHOSIS). They do not cure the patient, AMPUTATION). Known as TENS, its mode of
but do help to control his or her symptoms so action appears to have some resemblance to that
that the person can live in the community and of ACUPUNCTURE. Several controlled trials sug-
be admitted to hospital only for acute episodes. gest that it provides at least a modicum of relief
The drug chosen depends upon the type of ill- of pain after operations, thereby reducing the
ness and needs of a particular patient as well as amount of ANALGESICS that may be called for.
the likely adverse effects. Antipsychotic drugs
modify the transmission of nerve-signals by Transfusion
making brain cells less sensitive to the excitatory The administration of any fluid into a persons
neurotransmitter chemical called DOPAMINE. vein using a drip. This apparatus facilitates a
Among the antipsychotic tranquillisers are continuous injection in which the fluid flows by
CHLORPROMAZINE, HALOPERIDOL, CLOZAPINE force of gravity from a suspended bottle, via a
and flupenthixol. tube that is fixed to a hollow needle inserted
Anxiety is a consequence of too much STRESS into a vein (usually in the front of the elbow).
and may occur without being serious enough to Saline solution, PLASMA and whole BLOOD (see
need treatment. Clinically it arises when the below) are the most commonly administered
balance between certain chemicals in the brain fluids. Saline is used to restore fluid to a ser-
is disturbed: this increases activity in the sympa- iously dehydrated individual (see DEHYDRA-
thetic system, thus provoking physical symp- TION) and may be used as a temporary measure
toms such as breathlessness, tachycardia, head- in SHOCK due to blood loss while the appropri-
aches and indigestion. Anxiolytics help to ate type of blood is being obtained for transfu-
alleviate these symptoms but do not necessarily sion. Saline may also be useful as a way of
cure the underlying cause. Two main classes of administering a regular supply of a drug over a
drug relieve anxiety: BENZODIAZEPINES and period of time. Plasma is normally used as a
beta blockers (see BETA-ADRENOCEPTOR- temporary measure in the treatment of shock
BLOCKING DRUGS). The latter, which include until appropriately matched blood is available
atenolol and propanolol, reduce the physical or if for any reason, such as for a patient with
symptoms such as tachycardia and are useful in severe burns, plasma is preferable to blood.
circumstances for example, examinations
known to cause anxiety attacks. They block the Transfusion of blood is a technique that
action of NORADRENALINE, a key chemical of has been used since the 17th century
the sympathetic nervous system. Benzo- although, until the 20th century, with a sub- T
diazepines depress activity in that part of the sequent high mortality rate. It was only when
brain controlling emotion by stimulating the incompatibility of BLOOD GROUPS was con-
action of a chemical called gamma- sidered as a potential cause of this high mortal-
aminobutyric acid (GABA). Among the benzo- ity that routine blood-testing became standard
diazepines are chlordiazepoxide and diazepam. practice. Since the National Blood Transfusion
(See also MENTAL ILLNESS.) Service was started in the United Kingdom (in
1946), blood for transfusion has been collected
Transcervical Resection of from voluntary, unpaid donors: this is screened
Endometrium (TCRE) for infections such as SYPHILIS, HIV, HEPATITIS
An operation, usually done under local anaes- and nvCJD (see CREUTZFELDT-JAKOB DISEASE
thetic, in which the lining membrane of the (CJD)), sorted by group, and stored in blood-
UTERUS (womb) is excised using a type of LASER banks throughout the country.
or DIATHERMY surgery that utilises a hyster- In the UK in 2004, the National Blood
escope (a variety of ENDOSCOPE) through Authority todays transfusion service
 724 Transfusion

announced that it would no longer accept and a substance called perflubron, the mol-
donations from anyone who had received a ecules of which store oxygen and absorb carbon
blood transfusion since 1980 because of the dioxide more effectively than does haemo-
remote possibility that they might have been globin. Within 24 hours of being transfused
infected with the PRION which causes nvCJD. into a persons bloodstream, perflubron evapor-
A standard transfusion bottle has been ates and is harmlessly breathed out by the
developed, and whole blood may be stored at recipient. Artificial blood is especially valuable
26 C for three weeks before use. Transfusions in that it contains no unwanted proteins that
may then be given of whole blood, plasma, can provoke adverse immunological reactions.
blood cells, or PLATELETS, as appropriate. Furthermore, it is disease-free, lasts for up to
Stored in the dried form at 421 C, away from three years and is no more expensive than donor
direct sunlight, human plasma is stable for five blood. It could well take the place of donor
years and is easily reconstituted by adding ster- blood within a few years.
ile distilled water.
The National Blood Authority prepares sev- Autologous transfusion is the use of an
eral components from each donated unit of individuals own blood, provided in advance,
blood: whole blood is rarely used in adults. This for transfusion during or after a surgical oper-
permits each product, whether plasma or vari- ation. This is a valuable procedure for oper-
ous red-cell concentrates, to be stored under ations that may require large transfusions or
ideal conditions and used in appropriate clinical where a person has a rare blood group. Its use
circumstances say, to restore blood loss or to has increased for several reasons:
treat haemostatic disorders. fear of infection such as HIV and hepatitis.
Transfusion of blood products can cause
complications. Around 5 per cent of transfused
shortages of donor blood and the rising cost
of units of blood.
patients suffer from a reaction; most are mild,
but they can be severe and occasionally fatal. It
substantial reduction of risk of incompatible
transfusions.
can be difficult to distinguish a transfusion reac- In practice, blood transfusion in the UK is
tion from symptoms of the condition being remarkably safe, but there is always room for
treated, but the safe course is to stop the trans- improvement. So, in the 1990s, a UK inquiry
fusion and start appropriate investigation. on the Serious Hazards of Transfusion (SHOT)
In the developed world, clinicians can expect was launched. It established (1998) that of 169
to have access to high-quality blood products, recently reported serious hazards following
with the responsibility of providing blood rest- blood transfusion, 81 had involved a blood
ing with a specially organised transfusion ser- component being given to the wrong patient,
vice. The cause of most fatal haemolytic trans- while only eight were the result of viral or bac-
fusion reactions is a clerical error due to faulty terial infections.
labelling and/or failure to identify the recipient There are three ways to use a patients own
correctly. Hospitals should have a strict proto- blood in transfusion:
col to prevent such errors. (1) predeposit autologous donation (PAD)
taking blood from a patient before oper-
Artificial blood Transfusion with blood ation and transfusing this blood back into
from donors is facing increasing problems. the patient as required during and after
Demand is rising; suitable blood donors are operation.
T becoming harder to attract; the processes of tak- (2) acute normovalaemic haemodilution
ing, storing and cross-matching donor blood (ANH) diluting previously withdrawn
are time-consuming and expensive; the shelf- blood and thus increasing the volume
life is six weeks; and the risk of adverse reactions before transfusion.
or infection from transfused blood, although (3) perioperative cell salvage (PCS) the use of
small, is always present. Artificial blood would centrifugal cell separation on blood saved
largely overcome these drawbacks. Several during an operation, particularly spinal
companies in North America are now preparing surgery where blood loss may be
this: one product uses purified HAEMOGLOBIN considerable.
from humans and another from cows. These The government has urged NHS trusts to
provide oxygen-carrying capacity, are unlikely consider the introduction of PCS as a possible
to be infectious and do not provoke immuno- adjunct or alternative to banked-blood transfu-
logical rejections. Yet another product, called sion. In one centre (Nottingham), PCS has
Oxygene, does not contain any animal or been used in the form of continuous autologous
human blood products; it comprises salt water transfusion for several years with success.
 Transplantation 725

Exchange transfusion is the method of Other organs that have been transplanted
treatment in severe cases of HAEMOLYTIC DIS- with increasing success are the heart, the lungs,
EASE OF THE NEWBORN. It consists of replacing the liver, bone marrow, and the cornea of the
the whole of the babys blood with Rh-negative eye. Heart, lung, liver and pancreas transplanta-
blood of the correct blood group for the baby. tions are now carried out in specialist centres. It
is estimated that in the United Kingdom,
Transient Ischaemic Attacks or approximately 200 patients a year between the
Episodes (TIA, TIE) ages of 15 and 55 would benefit from a liver
Episodes of transient ISCHAEMIA of some part transplant if an adequate number of donors
of the cerebral hemispheres or the brain stem were available. More than 100 liver transplants
(see BRAIN) lasting anything from a few minutes are carried out annually in the United Kingdom
to several hours and followed by complete and one-year-survival rates of up to 80 per cent
recovery. By definition, the ischaemic episode have been achieved.
must be less than 24 hours. These episodes may The major outstanding problem is how to
be isolated or they may occur several times in a prevent the recipients body from rejecting and
day. The cause is ATHEROMA of the carotid or destroying the transplanted organ. Such rejec-
vertebral arteries (see ARTERIES, DISEASES OF) tion is part of the normal protective mechanism
and the embolisation (see EMBOLISM) of PLATE- of the body (see IMMUNITY). Good progress has
LETS or CHOLESTEROL. These attacks present been made in techniques of tissue-typing and
with strokes (see STROKE) that rapidly recover. immunosuppression to overcome the problem.
Drugs are now available that can suppress the
Translocation immune reactions of the recipient, which are
The term used to describe an exchange of gen- responsible for the rejection of the transplanted
etic material between CHROMOSOMES. It is an organ. Notable among these are CICLOSPORIN
important factor in the etiology, or causation, A, which revolutionised the success rate, and
of certain congenital abnormalities such as, for TACROLIMUS, a macrolide immunosuppressant.
example, DOWNS (DOWN) SYNDROME. It is one Another promising development is anti-
of the main abnormalities sought for in lymphocytic serum (ALS), which reduces the
AMNIOSCOPY. activity of the lymphocytes (see LYMPHOCYTE)
cells which play an important part in maintain-
Transplantation ing the integrity of the body against foreign
Transplantation of tissues or organs of the body bodies.
are defined as an allotransplant, if from another Donor cards are now available in all general
person; an autotransplant, if from the patient practitioners surgeries and pharmacies but, of
him or herself for example, a skin graft (see the millions of cards distributed since 1972, too
GRAFT; SKIN-GRAFTING); and a xenotransplant, few have been used. The reasons are complex
if from an animal. but include the reluctance of the public and
The pioneering success was achieved with doctors to consider organ donation; poor
transplantation of the kidney in the 1970s; this organisation for recovery of donor kidneys; and
has been most successful when the transplanted worries about the diagnosis of death. A code of
kidney has come from an identical twin. Less practice for procedures relating to the removal
successful have been live transplants from other of organs for transplantation was produced in
blood relatives, while least successful have been 1978, and this code has been revised in the light
transplants from other live donors and cadaver of further views expressed by the Conference of T
donors. The results, however, are steadily Medical Royal Colleges and Faculties of the
improving. Thus the one-year functional sur- United Kingdom on the Diagnosis of Brain
vival of kidneys transplanted from unrelated Death. Under the Human Tissue Act 1961,
dead donors has risen from around 50 per cent only the person lawfully in possession of the
to over 80 per cent, and survival rates of 80 per body or his or her designate can authorise the
cent after three years are not uncommon. For a removal of organs from a body. This authorisa-
well-matched transplant from a live related tion may be given orally.
donor, the survival rate after five years is around Patients who may become suitable donors
90 per cent. And, of course, if a transplanted after death are those who have suffered severe
kidney fails to function, the patient can always and irreversible brain damage since such
be switched on to some form of DIALYSIS. In the patients will be dependent upon artificial venti-
United Kingdom the supply of cadaveric (dead) lation. Patients with malignant disease or sys-
kidneys for transplantation is only about half temic infection, and patients with renal disease,
that necessary to meet the demand. including chronic hypertension, are unsuitable.
 726 Transplant Support Services Authority

If a patient carries a signed donor card or has favour, following protocols set by advisory
otherwise recorded his or her wishes, there is no groups. It also administers the Human Organ
legal requirement to establish lack of objection Transplant Act on behalf of the Department of
on the part of relatives although it is good Health. (See TRANSPLANTATION.)
practice to take account of the views of close
relatives. If a relative objects, despite the known Trans-Sexualism
request by the patient, staff will need to judge, The psycho-sexual condition characterised by
according to the circumstances of the case, feelings of belonging to the gender opposite to
whether it is wise to proceed with organ that of the genitalia and the secondary sex char-
removal. If a patient who has died is not known acteristics. Subjects may be helped by counsel-
to have requested that his or her organs be ling, drug therapy and in some circumstances
removed for transplantation after death, the an operation to change their physical sexual
designated person may only authorise the characteristics. Trans-sexuals or their families
removal if, having made such reasonable wanting help and guidance should contact the
enquiry as may be practical, he or she has no Gender Identity Consultancy.
reason to believe (a) that the deceased had
expressed an objection to his or her body being Transudation
so dealt with after death, or (b) that the surviv- The passage of liquid called the transudate
ing spouse or any surviving relative of the through a membrane: for example, the passage
deceased objects to the body being so dealt of blood through the wall of a capillary vessel.
with. Staff will need to decide who is best
qualified to approach the relatives. This should Transurethral Resection
be someone with appropriate experience who is The use of a special CYSTOSCOPE (a resectos-
aware how much the relative already knows cope) inserted through the URETHRA to resect
about the patients condition. Relatives should the PROSTATE GLAND or bladder tumours. (See
not normally be approached before death has also RESECTION.)
occurred, but sometimes a relative approaches
the hospital staff and suggests some time in Transverse
advance that the patients organs might be used An anatomical description of a line, plane or
for transplantation after death. The staff of structure at right-angles to the long axis of an
hospitals and organ exchange organisations organ or the body.
must respect the wishes of the donor, the recipi-
ent and their families with respect to Transvestitism
anonymity. Also called transvestism. The term given to a
Relatives who enquire should be told that psycho-sexual condition in which there is a
some post-mortem treatment of the donors repetitive compulsion to dress in the clothes of
body will be necessary if the organs are to be the opposite sex to achieve ORGASM.
removed in good condition. It is ethical (see
ETHICS) to maintain artificial ventilation and Tranylcypromine
heartbeat until removal of organs has been One of the monoamine oxidase inhibitor
completed. This is essential in the case of heart ANTIDEPRESSANT DRUGS.
and liver transplants, and many doctors think it
is desirable when removing kidneys. Official Trapezium
T criteria have been issued in Britain to recognise A bone in the wrist, one of the carpal group (see
when BRAIN-STEM DEATH has occurred. This is HAND).
an important protection for patients and rela-
tives when someone with a terminal condition Trauma
usually as a result of an accident is con- A term used in a physical sense as a wound or
sidered as a possible organ donor. injury such as a severe blow, maybe leading
to a fracture. Physical traumas such as events
Transplant Support Services of birth, severe accidents and any form of
Authority childhood or sexual abuse are considered to
In the UK, this NHS authority (UKTSSA) be overwhelming stressful events and regarded
provides a 24-hour service for matching, allo- as psychological traumas. Various scoring
cating and distributing organs. It is also respon- techniques have been formed for traumas;
sible for keeping the records of all patients generally seen as numerical systems for assess-
awaiting transplants. Established in 1991, the ing the severity and prognosis of severe
authority allocates donor organs without injuries.
 Trendelenberg Position 727

Traumatology ROID GLAND, DISEASES OF); very fine tremors,

Branch of SURGERY specialising in the treat- visible in the muscles of face or limbs and
ment of wounds and disabilities arising from known as fibrillary tremors, are present in gen-
injuries. eral paralysis of the insane (see SYPHILIS), and in
progressive muscular atrophy or wasting palsy.
Travel Medicine Tremors may occur at rest and disappear on
Many countries have reciprocal health movement as in Parkinsonism, or they may
arrangements with Britain under which British occur only on movement (intention tremors) as
visitors may receive emergency treatment free in cerebellar disease.
or at reduced cost. Information about these
arrangements is available from any local DSS Trench Fever
office. General and specific advice for travel- An infectious disease caused by Rickettsia quin-
lers on such matters as immunisations needed tana which is transmitted by the body louse.
can be obtained from their general prac- Large epidemics occurred among troops on
titioner, through travel agents or one of the active service during World War I. It recurred
high street travel health shops. Travellers are on a smaller scale in World War II, but is now
advised to consult a doctor if they develop an rare.
illness after an overseas visit: some tropical
disorders may take days or even weeks to pro- Trench Foot
duce symptoms. This is due to prolonged exposure of the feet to
water particularly cold water. Trench warfare
Travel Sickness is a common precipitating factor, and the con-
Sickness induced by any form of transport, dition was rampant during World War I. Cases
whether by sea, air, motor-car or train. (See also also occurred during World War II and during
MOTION (TRAVEL) SICKNESS.) the Falklands campaign. (The less common
form, due to warm-water immersion, occurred
Travellers diarrhoea is an all-too- with some frequency in the Vietnam war.) It is
common affliction of the traveller, which basks characterised by painful swelling of the feet
in a multiplicity of names: for example, Aden accompanied in due course by blistering and
gut, Aztec two-step, Basra belly, Delhi belly, ulceration which, in severe, untreated cases,
Gippy tummy, Hong Kong dog, Montezumas may progress to GANGRENE. In mild cases
revenge, Tokyo trots, turista. It is caused by a recovery may be complete in a month, but
variety of micro-organisms, usually E. coli. severe cases may drag on for a year. (See also
Some people seem to be more prone to it than IMMERSION FOOT.)
others, although for no good cause. Obvious
preventive measures include the avoidance of Treatment Drying of the feet overnight,
salads, unpeeled fruit and ice cream, and never where practicable, is the best method of preven-
drinking unboiled or unbottled water. If diar- tion, accompanied by avoidance of constrictive
rhoea occurs, co-phenotrope and loperamide clothing and tight boots, and of prolonged
are often used to reduce the frequency of bowel immobility. Frequent rest periods and daily
movements in adults. Prophylactic antibacterial changing of socks also help. The application of
drugs are not advisable. silicone grease once a day is another useful pre-
ventive measure. In the early stages, treatment
Tremor consists of rest in bed and warmth; in more T
A fine involuntary movement. Tremors may be severe cases treatment is as for infected tissues
seen in projecting parts like the hands, head and and ulceration. ANALGESICS are usually neces-
tongue, or they may involve muscles. Coarse sary to ease the pain. Technically, smoking
tremors, which prevent a person from drinking should be forbidden, but the adverse psycho-
a glass of water without spilling it, are found in logical effects of this in troops on active service
MULTIPLE SCLEROSIS (MS) and in CHOREA; may outweigh its advantages.
somewhat finer tremors, which produce trem-
bling of the hands or tongue when they are Trendelenberg Position
stretched out, are caused by alcoholism (see This is a steep head-down tilt so that the
ALCOHOL) and other forms of poisoning, by patients pelvis and legs lie above the heart. It is
PARKINSONISM, and by the weakness which fol- used to improve access, and to limit blood loss,
lows some acute disease or characterises old age. during surgery to the pelvis. It has been used to
A fine tremor of the outstretched fingers is a treat shocked patients (see SHOCK), but, as the
characteristic of thyrotoxicosis (see under THY- position increases pressure on the DIAPHRAGM
 728 Trepanning

and embarrasses breathing, raising the legs by the skin and joints by local injection.
themselves is better.
Triceps
Trepanning A muscle of the posterior upper arm which acts
An operation in which a portion of the CRA- to extend the forearm. So-named because it
NIUM is removed. Originally the operation was originates from three heads.
performed with an instrument resembling a
carpenters brace and known as the trephine or Trichiasis
trepan, which removes a small circle of bone; A condition in which the eyelashes become
but now this instrument is only used, as a rule, ingrown. (See EYE, DISORDERS OF.)
for making small openings, whilst, for wider
operations, gouge forceps, circular saws driven Trichiniasis
by electric motor, or wire saws are used. See TRICHINOSIS.
Trepanning is used in cases of fracture, with
splintering of the skull; the operation is per- Trichinosis
formed to remove fragments of bone and any Trichinosis, or trichiniasis, is a disease caused by
foreign bodies, like a bullet, which may have eating meat infected with the parasitic nema-
entered. In compression of the brain with tode worm, Trichinella spiralis. Although it
unconsciousness following an injury, the skull is infects more than 100 animal species, this
trephined and any blood clots removed, or torn nematode usually infects humans via pig meat
vessels ligatured. The operation may also be in which the immature spiralis is encysted. The
done for an ABSCESS within the skull and for full-grown female worm, which inhabits the
other conditions where operative access to the intestine, is 3 mm in length, and the larvae, to
brain is required. whose movements the disease is due, are much
smaller. The disease is acquired by eating raw or
Trephining underdone pork from pigs that have been
See TREPANNING. infected with the worm. When such a piece of
meat is eaten, the embryos contained in it are
Treponema set free and develop into full-grown trichinellae;
The name of a genus of spirochaetal micro- from each pair of these, 1,000 or more new
organisms which consist of slender spirals and embryos may arise in a few weeks. These bur-
which progress by means of bending move- row through the walls of the gut, spread
ments. Treponema pallidum (formerly called throughout the body and settle in voluntary
Spirochaeta pallida) is the causative organism of muscle.
SYPHILIS.
Prevention is based on thorough inspection
Triage of meat in slaughterhouses; even cooking,
Derived from the French word for sorting, tri- unless the meat is in slices, is not an efficient
age is a universal term applied to methods of protection. Pigs should not be fed on unboiled
allocating treatment prioritisations for casual- garbage. Rats may be a source of sporadic out-
ties from disasters or in warfare. The procedure breaks, as infected rats have been found near
helps a medical team to treat casualties who, piggeries. The disease is widely distributed
although badly injured, can be saved; to defer throughout the Americas, Asia, Africa and the
T those whose treatment is less urgent; and to Arctic. Sporadic cases and epidemics occur and
provide care and comfort for those with fatal outbreaks also appear in Europe, although
injuries. rarely in Britain.
Triage is now operated in accident and emer-
gency departments by a triage nurse who allo- Treatment Thiabendazole or mebendazole
cates a degree of priority so that patients are are usually effective, while STEROID treatment
seen in order of severity rather than according helps patients with systemic illness and muscle
to their time of arrival. tenderness.

Triamcinolone Tricho-
One of the CORTICOSTEROIDS with a potency Tricho- is a prefix denoting relation to hair.
equivalent to that of PREDNISONE, but less
likely to cause retention of sodium. It is used for Trichomonas Vaginalis
the suppression of inflammatory and allergic A protozoon normally present in the VAGINA of
disorders, and is used particularly for treating about 3040 per cent of women. It sometimes
 Trigeminal Neuralgia 729

becomes pathogenic and causes inflammation heart failure may result and treatment is similar,
of the genital passages, with vaginal discharge. with surgery to repair or replace the faulty valve
A man may become infected as a result of sexual an option.
intercourse with an infected woman and suffer
from a urethral discharge; it may also cause Tricuspid Valve
prostatitis (see under PROSTATE GLAND, DISEASES The valve, with three cusps or flaps, that guards
OF). METRONIDAZOLE is usually an effective the opening from the right atrium into the right
treatment, and to obtain a satisfactory result it ventricle of the HEART.
may be necessary to treat both partners. Should
metronidazole not work, then tinidazole may Tricyclic Antidepressant Drugs
be tried. This group of drugs is one of three main types
of drugs used to treat DEPRESSION, and was the
Trichomoniasis first to be introduced (in the 1950s). Tricyclic
The disease caused by infection with TRI- drugs work by blocking the re-uptake of the
CHOMONAS VAGINALIS. neurotransmitters SEROTONIN and NORADREN-
ALINE (see NEUROTRANSMITTER), thus increas-
Trichophyton ing the amount of the neurotransmitters at the
See DERMATOPHYTES. nerve cells receptors. In people with depres-
sion, fewer neurotransmitters than normal are
Trichotillomania released, resulting in a slowing of neural activ-
An obsessional impulse to pull out ones own ities. The drugs have a sedative effect, which
hair. can be useful for depressives with sleep prob-
lems, and an antimuscarinic action which can
Trichuriasis cause dry mouth and constipation (see
A worldwide infection, particularly common in ANTIMUSCARINE). Overdosage can produce
the tropics. It is caused by Trichuris trichiura, or COMA, fits (see SEIZURE) and irregular heart
whipworm, so-called because of its shape the rhythm (ARRHYTHMIA). They are sometimes
rear end being stout and the front end hair-like, used for treating bed-wetting. (See also ANTI-
resembling the lash of a whip. The male meas- DEPRESSANT DRUGS.)
ures 5 cm and the female 4 cm in length. Infec-
tion results from eating vegetables, or drinking Trifluoperazine
water, polluted with the ova (eggs). These hatch See NEUROLEPTICS.
out in the large INTESTINE and the diagnosis is
made by finding the eggs in the stools (FAECES). Trigeminal Nerve
The worms seldom cause any trouble unless The fifth cranial nerve (arising from the BRAIN).
they are present in large numbers when, espe- It consists of three divisions: (1) the ophthalmic
cially in malnourished children, they may cause nerve, which is purely sensory in function,
bleeding from the bowels, ANAEMIA and PRO- being distributed mainly over the forehead and
LAPSE of the RECTUM. The most effective drug front part of the scalp; (2) the maxillary nerve,
is MEBENDAZOLE. which is also sensory and distributed to the skin
of the cheek, the mucous membrane of the
Tricuspid Incompetence mouth and throat, and the upper teeth; and (3)
Failure of the TRICUSPID VALVE in the HEART to the mandibular nerve, which is the nerve of
close fully, thus permitting blood to leak back sensation to the lower part of the face, the T
into the right atrium during contractions of the tongue and the lower teeth, as well as being the
right ventricle. This reduces the hearts pump- motor nerve to the muscles concerned in chew-
ing efficiency, and right-sided heart failure usu- ing. The trigeminal nerve is of special interest,
ally results. Treatment for heart failure (using owing to its liability to NEURALGIA TRI-
DIURETICS and ACE inhibitor drugs) usually GEMINAL NEURALGIA, or tic douloureux as it is
restores function, but sometimes heart surgery also known, being the most painful form
is required to repair or replace the defective known.
valve.
Trigeminal Neuralgia
Tricuspid Stenosis Also called tic douloureux, this is one of the
The normal working of the TRICUSPID VALVE in most severe forms of NEURALGIA. It affects the
the HEART is impeded by a narrowing of the main sensory nerve in the face (TRIGEMINAL
opening, often as a sequel of RHEUMATIC NERVE), and may occur in one or more of the
FEVER. As with TRICUSPID INCOMPETENCE, three divisions in which the nerve is distributed.
 730 Trigger Finger

It is usually confined to one side. It is more Tri-Iodothyronine

common in women than in men, usually occur- (T3) The substance which exerts the physio-
ring over the age of 50. The attack is often pre- logical action of thyroid hormone (see THYROID
cipitated by movements of the jaw, as in talking GLAND). It is formed in the body cells by the
or eating, or by tactile stimuli such as a cold de-iodination of THYROXINE (tetra-
wind or washing the face. When the first or iodothyronine) which is the active principle
upper division of the nerve is involved, the pain secreted by the thyroid gland. It has also been
is mostly felt in the forehead and side of the synthesised, and is now available for the treat-
head. It is usually of an intensely sharp, cutting, ment of hypothyroidism (see THYROID GLAND,
or burning character, either constant or with DISEASES OF). It is three times as potent as
exacerbations each day while the attack con- thyroxine.
tinues. There is also pain in the eyelid, redness
of the eye and increased flow of tears. When the Trimester
second division of the nerve is affected, the pain A period of three months. Normal human GES-
is chiefly in the cheek and upper jaw. When the TATION is divided into three trimesters see
third division of the nerve suffers, the pain PREGNANCY AND LABOUR.
affects the lower jaw. Attacks may recur for
years; and, although interfering with sleeping Trimethoprim
and eating, they rarely appear to lead to any Trimethoprim is an antibacterial agent used in
serious results. Nevertheless, the pain may the treatment of infections of the URINARY
become intolerable. TRACT. It is also a constituent of CO-
TRIMOXAZOLE a combination that should be
Treatment The outlook in trigeminal neur- used with caution as it can damage kidney func-
algia was radically altered by the introduction of tion. Trimethoprim is also used to treat acute
the drug CARBAMAZEPINE, which usually and chronic BRONCHITIS.
relieves the pain. If the side-effects for
example, dizziness, headache, nausea or drow- Trimipramine
siness are unacceptable or pain not relieved, One of the TRICYCLIC ANTIDEPRESSANT DRUGS
PHENYTOIN SODIUM may help. Otherwise, sur- which also acts as a sedative.
gery is needed in the shape of controlled, radio-
frequency heat damage to the appropriate part Trinitrin
of the trigeminal nerve. See GLYCERYL TRINITRATE.

Trigger Finger Trinitrophenol

Also called snapping finger. This is the condi- See PICRIC ACID.
tion in which, when the fingers are straightened
on unclenching the fist, one finger usually the Triplets
ring or middle finger remains bent. The cause See MULTIPLE BIRTHS.
is obscure. In severe cases treatment consists of
opening up the sheath surrounding the tendon Triple Vaccine
of the affected finger. When confined to the Also known as DPT vaccine, this is an injection
thumb, the condition is known as trigger that provides IMMUNITY against DIPHTHERIA,
thumb. pertussis (whooping-cough) and TETANUS. It is
T given as a course of three injections at around
Trigger Thumb the ages of two, three and four months. A
See TRIGGER FINGER. booster dose of diphtheria and tetanus is given
at primary-school age. Certain infants those
Triglyceride with a family history of EPILEPSY, or who have
A LIPID or neutral FAT comprising GLYCEROL neurological disorders or who have reacted
and three fatty-acid molecules. Triglycerides are severely to the first dose should not have the
manufactured in the body from the digested pertussis element of DPT. (See MMR VACCINE;
products of fat in the diet. Fats are stored in the IMMUNISATION.)
body as triglycerides.
Trismus
Trigone Another name for TETANUS.
The base of the URINARY BLADDER between the
openings of the two ureters (see URETER) and of Trocar
the URETHRA. An instrument provided with a sharp three-sided
 Truss 731

point fitted inside a tube or cannula, and used importation of tropical diseases to temperate
for puncturing cavities of the body in which climates should be borne in mind when people
fluid has collected. fall ill.
The following diseases and conditions are
Trochanter treated under their separate dictionary entries:
The name given to two bony prominences at ANCYLOSTOMIASIS; BERIBERI; BLACKWATER
the upper end of the thigh-bone (FEMUR). FEVER; CHOLERA; DENGUE; DRACONTIASIS;
The greater trochanter can be felt on the outer DYSENTERY; ELEPHANTIASIS; FILARIASIS; HEAT
side of the thigh; the lesser trochanter is a STROKE; LEISHMANIASIS; LEPROSY; LIVER, DIS-
small prominence on the inner side of this EASES OF; MALARIA; ORIENTAL SORE; PLAGUE;
bone. PRICKLY HEAT; SCHISTOSOMIASIS; SLEEPING
SICKNESS; STRONGYLOIDIASIS; SUNBURN; YAWS;
Trochlear Nerve YELLOW FEVER.
The fourth cranial nerve (arising from the
BRAIN), which acts upon the superior oblique Tropical Medicine
muscle of the EYE. The diagnosis and treatment of diseases that
occur most commonly in tropical zones of the
Trophic world. Examples are LEPROSY, MALARIA, SCHIS-
A term applied to the influence that nerves TOSOMIASIS and TRYPANOSOMIASIS. With the
exert with regard to the healthiness and nour- great increase in international travel in the past
ishment of the parts to which they run. When 30 or so years, TROPICAL DISEASES are appearing
the nerves become diseased or injured, this more often in temperate climates. Global
influence is lost and the muscles waste, while warming may also be enlarging the areas in
the skin loses its healthy appearance and is which tropical disorders naturally occur.
liable to break down into ulcers (see ULCER).
Tropical Ulcer
Trophoblast Also called Nagra sore, this is a skin disease of
The outer layer of the fertilised OVUM which unknown cause occurring in humid tropical
attaches the ovum to the wall of the UTERUS (or areas. A simple wound or abrasion develops
womb) and supplies nutrition to the EMBRYO. into an open sloughing sore that commonly
occurs on the leg or foot. The ULCER is often
Trophozoite infected with spirochaetes (see SPIROCHAETE)
A stage in the life of the parasite Plasmodium, and BACTERIA and may be so deep as to destroy
that is the cause of MALARIA. It has a ring- muscle and bone. Antiseptic dressing and an
shaped body and single nucleus and grows in antibiotic, usually PENICILLIN (by intra-
the blood cell, after which it divides to form a muscular injection), is the best treatment.
schizont. Sometimes a skin-graft is required to produce
healing (see GRAFT; SKIN-GRAFTING).
Tropical Diseases
Technically, those diseases occurring in the area Trunk
of the globe situated between the Tropic of A major vessel or nerve from which lesser ones
Cancer and the Tropic of Capricorn: pertaining arise; or the main part of the body excluding the
to the sun. They include many exotic infec- head, neck and limbs.
tions many of them parasitic in origin T
which fall under the umbrella of TROPICAL Truss
MEDICINE. However, disease in the tropics is A device used to support a HERNIA; or to retain
far broader than this and includes numerous the protruding organ within the cavity from
other infections, many of them with a viral or which it tends to pass. Every truss possesses a
bacterial basis: for example, the viral hepa- pad of some sort to cover the opening and a belt
tidises, streptococcal and pneumococcal infec- or spring to keep it in position.
tions, and tuberculosis. The prevalence of Before applying a truss the wearer must make
other diseases, such as rheumatic cardiac dis- certain that the hernia has been reduced; this
ease, cirrhosis, heptocellular carcinoma may mean lying down beforehand. A truss will
(hepatoma), and various nutrition-related rarely control a hernia satisfactorily, and it
problems, is also much increased in most areas should be considered as a temporary measure
of the tropics. With people from developed only until surgical correction is possible. In the
countries increasingly travelling to worldwide past, trusses have been supplied to patients con-
destinations for business and holiday, the sidered too frail for surgery, but modern anaes-
 732 Trypanosoma

thetic techniques mean that most people can Tubercle

have their hernias surgically repaired. The term is used in two distinct senses. As a
descriptive term in anatomy, a tubercle means a
Trypanosoma small elevation or roughness upon a BONE, such
A genus of microscopic parasites, several of as the tubercles of the ribs. In the pathological
which are responsible for causing SLEEPING sense, a tubercle is a small mass, barely visible to
SICKNESS and some allied diseases. the naked eye, formed in some organ as the
starting-point of TUBERCULOSIS. The name of
Trypanosomiasis tubercle bacillus was originally given to the
See SLEEPING SICKNESS. micro-organism that causes this disease, but was
subsequently changed to Mycobacterium tuber-
Trypsin culosis. The term tubercular should strictly be
The chief protein ENZYME of the pancreatic applied to anything connected with or resem-
secretion. Secreted by the PANCREAS as tryp- bling tubercles or nodules, and the term tuber-
sinogen (an inactive form), it is converted in the culous to anything pertaining to the disease
duodenum by another enzyme, enteropepti- tuberculosis.
dase. It changes proteins into peptones and
forms the main constituent of pancreatic Tuberculide
extracts used for digestion of food. (See PEPTON- The term given to any skin lesion which is the
ISED FOODS.) result of infection with the tubercle bacillus,
or Mycobacterium tuberculosis as it is now
Tryptophan known.
(1) One of the nine indispensable (essential)
AMINO ACIDS. Like other amino acids, trypto- Tuberculin
phan is needed by the body to synthesise the Tuberculin is the name originally given by Koch
proteins necessary for its growth and function- in 1890 to a preparation derived from the
ing. The description indispensable previously tubercle bacillus, or Mycobacterium tuberculosis
the adjective used was essential is applied as it is now known, and intended for the diag-
because the body is unable to manufacture nosis or treatment of TUBERCULOSIS.
these amino acids, which have to be obtained
from food or drink. Varieties
(2) A drug that has helped some patients with OLD TUBERCULIN (OT) is the heat-concentrated
resistant DEPRESSION. Used as a supporting filtrate from a fluid medium on which the
drug with other treatment, tryptophan was human or bovine type of Mycobacterium tuber-
withdrawn because of side-effects; it has, how- culosis has been grown for six weeks or more.
ever, been reintroduced for use in hospital for TUBERCULIN PURIFIED PROTEIN DERIVATIVE
patients for whom no alternative treatment is (TUBERCULIN PPD) is the active principle of OT
suitable. (See also MENTAL ILLNESS.) (see above), and is prepared from the fluid
medium on which the Mycobacterium tubercu-
Tsetse Fly losis has been grown. It is supplied as a liquid, a
An African fly of the genus Glossina. One or powder, or as sterile tablets. The liquid contains
more of these is responsible for carrying the 100,000 units per millilitre, and the dry powder
trypanosome which causes SLEEPING SICKNESS contains 30,000 units per milligram. It is dis-
T and thus spreads the disease among cattle and tributed in sterile containers sealed so as to
from cattle to humans. exclude micro-organisms. It is more constant in
composition and potency than OT.
Tsutsugamushi
Also called Japanese river fever, this is a disease Uses The basis of the tuberculin reaction is
of the typhus group. (See TYPHUS FEVER.) that any person who has been infected with the
Mycobacterium tuberculosis gives a reaction
Tubal Pregnancy when a small amount of tuberculin is injected
Also known as ECTOPIC PREGNANCY. Implant- into the skin. A negative reaction means either
ation of the EMBRYO in one of the FALLOPIAN that the individual has never been infected with
TUBES, rather than in the lining of the UTERUS. the tubercle bacillus, or that the infection has
The patient usually complains of pain between been too recent to have allowed of sensitivity
six and ten weeks gestation and, if the Fallopian developing.
tube is not removed, there may be rupture with There are various methods of carrying out
potentially life-threatening haemorrhage. the test, of which the following are the most
 Tuberculosis 733

commonly used. The Mantoux test is the most been recognised from earliest times. Evidence of
satisfactory of all, and has the advantage that the condition has been found in Egyptian
the size of the reaction is a guide to the severity mummies; in the fourth century BC Hippocra-
of the tuberculous infection: it is performed by tes, the Greek physician, called it phthisis
injecting the tuberculin into the skin on the because of the lung involvement; and in 1882
forearm. The Heaf multiple puncture test is Koch announced the discovery of the causative
reliable: it is carried out with the multiple punc- organism, the tubercle bacillus or Mycobacte-
ture apparatus, or Heaf gun. The Vollmer patch rium tuberculosis.
test, using an impregnated filter paper, is useful The symptoms depend upon the site of the
in children because of the ease with which it can infection. General symptoms such as fever,
be carried out. weight loss and night sweats are common. In
the most common form of pulmonary tubercu-
Tuberculosis losis, cough and blood-stained sputum
Tuberculosis results form infection with Myco- (haemoptysis) are common symptoms.
bacterium tuberculosis. The lungs are the site The route of infection is most often by
most often affected, but most organs in the inhalation, although it can be by ingestion of
body can be involved in tuberculosis. The other products such as infected milk. The results of
common sites are LYMPH NODES, bones, gastro- contact depend upon the extent of the
intestinal tract, kidneys, skin and MENINGES. exposure and the susceptibility of the indi-
The weight loss and wasting associated with vidual. Around 30 per cent of those closely
tuberculosis before treatment was available led exposed to the organism will be infected, but
to the diseases popular name of consumption. most will contain the infection with no signifi-
Enlargement of the glands in the neck, formerly cant clinical illness and only a minority will go
called scrofula, was known also as the kings on to develop clinical disease. Around 5 per
evil from the supersition that a touch of the cent of those infected will develop post-
royal hand could cure the condition. Lupus primary disease over the next two or three
vulgaris (see under LUPUS) is another of the skin years. The rest are at risk of reactivation of the
manifestations of the disease. disease later, particularly if their resistance is
The typical pathological change in tubercu- reduced by associated disease, poor nutrition
losis involves the formation of clusters of cells or immunosuppression. In developed countries
called granulomas (see GRANULOMA) with death around 5 per cent of those infected will
of the cells in the centre producing CASEATION. reactivate their healed tuberculosis into a clin-
It is estimated that there are 78 million new ical problem.
cases of tuberculosis worldwide each year, with Immunosuppressed patients such as those
23 million deaths. The incidence of tubercu- infected with HIV are at much greater risk of
losis in developed countries has shown a steady developing clinical tuberculosis on primary
decline throughout the 20th century, mainly as contact or from reactivation. This is a particular
a result of improved nutrition and social condi- problem in many developing countries, where
tions and accelerated by the development of there is a high incidence of both HIV and
antituberculous chemotherapy in the 1940s. tuberculosis.
Since the mid-1980s the decline has stopped,
and incidence has even started to rise again in Diagnosis This depends upon identification
inner-city areas. In 2002, 7,239 cases of tuber- of mycobacteria on direct staining of sputum or
culosis were notified in the UK compared with other secretions or tissue, and upon culture of T
6,442 a decade earlier; more than 390 deaths in the organism. Culture takes 46 weeks but is
2003 were attributed to the disease. Factors necessary for differentiation from other non-
involved in this rise are immigration from tuberculous mycobacteria and for drug-
higher-prevalence areas, poorer social condi- sensitivity testing. Newer techniques involving
tions and homelessness in some urban centres DNA amplification by polymerase chain
and the association with HIV infection and drug reaction (PCR) can detect small numbers of
abuse. The incidence of tuberculosis is also ris- organisms and help with earlier diagnosis.
ing in many developing countries because of
the emergence of resistant strains of the tubercle Treatment This can be preventative or cura-
bacillus (see below). In the UK recently there tive. Important elements of prevention are
have been serious outbreaks in a handful of adequate nutrition and social conditions, BCG
urban-based schools. vaccination (see IMMUNISATION), an adequate
public-health programme for contact tracing,
Nature of the disease Tuberculosis has and chemoprophylaxis. Radiological screening
 734 Tuberous Sclerosis

with mass miniature radiography is no longer oma sebaceum), fibrous outgrowths around the
used. nails and fibrous plaques on the lower back
Vaccination with an attenuated organism (shagreen patch) can all occur. Half of those
(BCG Bacillus Calmette Guerin) is used in affected have learning difficulties and behaviour
the United Kingdom and some other countries problems, and autistic symptoms may occur (see
at 1213 years, or earlier in high-risk groups. AUTISM).
Some studies show 80 per cent protection Characteristic white streaks appear on the
against tuberculosis for ten years after optic fundi (see EYE). Molecular genetic testing
vaccination. can identify up to 90 per cent of individuals
Cases of open tuberculosis need to be identi- with a tuberin gene. Genetic counselling of
fied; their close contacts should be reviewed for families is helpful. Relatives of those with this
evidence of disease. Adequate antibiotic chemo- condition can obtain help and guidance from
therapy removes the infective risk after around the Tuberous Sclerosis Association of Great
two weeks of treatment. Chemoprophylaxis Britain.
the use of antituberculous therapy in those
without clinical disease may be used in con- Tubocurarine
tacts who develop a strong reaction on tubercu- A voluntary-muscle relaxant given by intraven-
lin skin testing or those at high risk because of ous injection before surgery under general
associated disease. ANAESTHESIA. The drug is also used to treat
The major principles of antibiotic chemo- conditions such as TETANUS, ENCEPHALITIS and
therapy for tuberculosis are that a combination POLIOMYELITIS in which severe muscle spasms
of drugs needs to be used, and that treatment occur. Overdosage may result in respiratory
needs to be continued for a prolonged period failure because the muscles essential for breath-
usually six months. Use of single agents or ing are paralysed.
interrupted courses leads to the development of
drug resistance. Serious outbreaks of multiply Tubule
resistant Mycobacterium tuberculosis have been A small tube. There are several named tubules
seen mainly in AIDS units, where patients have in the body: examples include convoluted
greater susceptibility to the disease, but also in tubules in the NEPHRON of the kidney (see KID-
developing countries where maintenance of NEYS) and the seminiferous tubules in the testes
appropriate antibacterial therapy for six months (see TESTICLE).
or more can be difficult.
Streptomycin was the first useful agent iden- Tularaemia
tified in 1944. The four drugs used most often A disease of rodents such as rabbits and rats,
now are RIFAMPICIN, ISONIAZID, PYRAZINA- caused by the bacillus, Francisella tularense, and
MIDE and ETHAMBUTOL. Three to four agents spread either by flies or by direct inoculation
are used for the first two months; then, when for example, into the hands of a person
sensitivities are known and clinical response engaged in skinning rabbits. In humans the
observed, two drugs, most often rifampicin and disease takes the form of a slow fever lasting
isoniazid, are continued for the rest of the several weeks, with much malaise and depres-
course. Treatment is taken daily, although sion, followed by considerable emaciation. It
thrice-weekly, directly observed therapy is used was first described in the district of Tulare in
when there is doubt about the patients compli- California, and is found widely spread in North
T ance. All the antituberculous agents have a America and in Europe, but not in Great Brit-
range of adverse effects that need to be moni- ain. STREPTOMYCIN, the TETRACYCLINES and
tored during treatment. Provided that the CHLORAMPHENICOL offer effective treatment.
treatment is prescribed and taken appropriately,
response to treatment is very good with cure of Tulle Gras
disease and very low relapse rates. A wound dressing of gauze impregnated with
soft paraffin to prevent it from sticking to the
Tuberous Sclerosis wound.
Also called epiloia: a rare inherited disease
transmitted as an autosomal dominant trait. Tumescence
EPILEPSY in childhood is often the first mani- A swelling usually caused by blood or other
festation (see INFANTILE SPASMS), although body fluids accumulating in the tissues, often as
ovoid hypopigmented macules (ash leaf a consequence of injury. An erect PENIS, when
patches) in the skin may be detected in infancy. blood fills the corpus cavernosa in the organ, is
Later an ACNE-like eruption of the face (aden- sometimes described as tumescent.
 Tympanic Membrane 735

Tumour hollow
nature.
tumours or cysts, generally of simple
This literally means any swelling, but the term
does not usually include temporary swellings malignant tumours: (a) of cellular structure,
resembling the cells of skin, mucous mem-
caused by acute inflammation. The con-
sequences locally, however, of chronic inflam- brane, or secreting glands; (b) of connective
mation for example, TUBERCULOSIS, SYPHILIS tissue.
and LEPROSY are sometimes classed as
tumours, according to their size and appearance. Turgor
Being or becoming swollen or engorged.
Varieties Some are of an infective nature, as
already stated; some arise as the result of injury,
Turners Syndrome
This occurs in one in 2,500 live female births. It
and several contributing factors are mentioned
is caused by either the absence of or an
under the heading of CANCER.
abnormality in one of the two X CHROMO-
Traditionally tumours have been divided into
SOMES. Classical Turners syndrome is a com-
benign (simple) and malignant. Even benign
plete deletion of one X so that the karyotype is
tumours can be harmful, because their size or
45XO. Half of the people with Turners syn-
position may distort or damage nerves, blood
drome have MOSAICISM with a mixture of
vessels or organs. Usually, however, they are eas-
Turner cells and normal cells, or other
ily removed by surgery. Malignant tumours or
abnormalities of the X chromosome such as
cancers are harmful and potentially lethal, not
partial deletions or a ring X. They are females,
just because they erode tissues locally but
both in appearance and sexually; clinical fea-
because many of them spread, either by direct
tures are variable and include short stature, with
growth or by seeding to other parts metas-
final height between 1295 m and 1575 m, and
tasising. Malignant tumours arise because of
ovarian failure. Other clinical features may
an uncontrolled growth of previously normal
include a short neck, webbing of the neck,
cells. Heredity, environmental factors and life-
increased carrying angle at the elbow (cubitus
style all play a part in malignancy (see also
valgus), widely spaced nipples, cardiovascular
ONCOGENES). Symptoms are caused by local
abnormalities (of which the commonest is
spread and as a result of metastases. These
coarctation of the aorta [about 10 per cent]),
cause serious local damage, for example, in the
morphological abnormalities of the kidneys
brain or lungs, as well as disturbing the bodys
(including horseshoe kidney and abnormalities
metabolism. Unless treated with CHEMO-
of the pelviureteric tracts), recurrent otitis
THERAPY, RADIOTHERAPY or surgery or a com-
media (see under EAR, DISEASES OF), squints,
bination of these, malignant tumours are
increased incidence of pigmented naevi (see
ultimately fatal. Many, however, can now be
NAEVUS), hypothyroidism (see under THYROID,
cured. The original site and type of a malignant
DISEASES OF) and DIABETES MELLITUS. Intelli-
tumour usually determine the rate and extent
gence is across the normal range, although there
of spread.
are specific learning defects which are related to
The type of cell and organ site determine the
hand-eye coordination and spatial awareness.
characteristics of a malignant tumour. The
Patients with Turners syndrome may require
prognosis (outlook) for a patient with a malig-
therapeutic help throughout their life. In early
nant tumour depends largely upon how soon it
childhood this may revolve around surgical cor-
is diagnosed. Staging criteria have been
rection of cardiovascular disease and treatment
developed to assess the local and metastatic T
to improve growth. Usually, PUBERTY will need
spread of a tumour, its size and also likely sensi-
to be induced with oestrogen therapy (see OES-
tivity to the types of available treatment. The
TROGENS). In adult life, problems of oestrogen
ability to locate a tumour and its metastases
therapy, prevention of osteoporosis (see under
accurately has vastly improved with the intro-
BONE, DISORDERS OF), assessment and treat-
duction of radionuclide and ULTRASOUND
ment of HYPERTENSION and assisted fertility
scanning, CT scanning and magnetic resonance
predominate. For the address of the UK Turner
imaging (MRI). Screening for cancers such as
Syndrome Society, see Appendix 2.
those in the breast, cervix, colorectal region and
prostate help early diagnosis and usually Twins
improve treatment outcomes. See MULTIPLE BIRTHS.
Tumours are now classed according to the
tissues of which they are built, somewhat as Tympanic Membrane
follows: The ear-drum, which separates the external
simple tumours of normal tissue. and middle ear. (See EAR.)
 736 Tympanites

Tympanites spread over the chest, back and trunk. Death

Also known as meteorism. Distension of the may occur from SEPTICAEMIA, heart or kidney
abdomen due to the presence of gas or air in the failure, or PNEUMONIA about the 14th day. In
INTESTINE or in the peritoneal cavity (see PERI- those who recover, the temperature falls by CRI-
TONEUM). The abdomen when struck with the SIS at about this time. The death rate is variable,
fingers, gives under these conditions a drum- ranging from nearly 100 per cent in epidemics
like (tympanitic) note. among debilitated refugees to about 10 per
cent.
Tympanum
Another name for the middle EAR. Murine typhus fever, also known as flea
typhus, is worldwide in its distribution and is
Typhoid Fever found wherever individuals are crowded
See ENTERIC FEVER. together in insanitary, rat-infested areas (hence
the old names of jail-fever and ship typhus).
Typhus Fever The causative organism, Rickettsia mooseri,
An infective disease of worldwide distribution, which is closely related to R. prowazeki, is
the manifestations of which vary in different transmitted to humans by the rat-flea, Xenopsy-
localities. The causative organisms of all forms alla cheopis. The rat is the main reservoir of
of typhus fever belong to the genus RICKETT- infection; once humans are infected, the human
SIA. These are organisms which are intermedi- louse may act as a transmitter of the rickettsia
ate between bacteria and viruses in their prop- from person to person. This explains how the
erties, and measure 05 micrometre or less in disease may become epidemic under insanitary,
diameter. crowded conditions. As a rule, however, the dis-
ease is only acquired when humans come into
Louse typhus, in which the infecting rick- close contact with infected rats.
ettsia is transmitted by the louse, is of world-
wide distribution. More human deaths have Symptoms These are similar to those of
been attributed to the louse via typhus, louse- louse-borne typhus, but the disease is usually
borne RELAPSING FEVER and trench fever, than milder, and the mortality rate is very low (about
to any other insect with the exception of the 15 per cent).
MALARIA mosquito. Louse typhus includes epi-
demic typhus, Brills disease which is a Tick typhus, in which the infecting rickett-
recrudescent form of epidemic typhus and sia is transmitted by ticks, occurs in various
TRENCH FEVER. parts of the world. The three best-known con-
ditions in this group are ROCKY MOUNTAIN
Epidemic typhus fever, also known as SPOTTED FEVER, fivre boutonneuse and tick-
exanthematic typhus, classical typhus, and bite fever.
louse-borne typhus, is an acute infection of
abrupt onset which, in the absence of treat- Mite typhus, in which the infecting rickett-
ment, persists for 14 days. It is of worldwide sia is transmitted by mites, includes scrub
distribution, but is largely confined today to typhus, or tsutsugamushi disease, and
parts of Africa. The causative organism is the rickettsialpox.
Rickettsia prowazeki, so-called after Ricketts
T and Prowazek, two brilliant investigators of Rickettsialpox is a mild disease caused by
typhus, both of whom died of the disease. It is Rickettsia akari, which is transmitted to humans
transmitted by the human louse, Pediculus from infected mice by the common mouse
humanus. The rickettsiae can survive in the mite, Allodermanyssus sanguineus. It occurs in
dried faeces of lice for 60 days, and these the United States, West and South Africa and
infected faeces are probably the main source of the former Soviet Union.
human infection.
Treatment The general principles of treat-
Symptoms The incubation period is usually ment are the same in all forms of typhus.
1014 days. The onset is preceded by headache, PROPHYLAXIS consists of either avoidance or
pain in the back and limbs and rigors. On the destruction of the vector. In the case of louse
third day the temperature rises, the headache typhus and flea typhus, the outlook has been
worsens, and the patient is drowsy or delirious. revolutionised by the introduction of efficient
Subsequently a characteristic rash appears on insecticides such as DICHLORODIPHENYL TRI-
the abdomen and inner aspect of the arms, to CHLOROETHANE (DDT) and GAMMEXANE.
 Tyrosine 737

The value of the former was well shown by its Tyramine

use after World War II: this resulted in almost A variety of the chemical compound amine,
complete freedom from the epidemics of which is derived from ammonia. A sympatho-
typhus which ravaged Eastern Europe after mimetic agent with an action which resembles
World War I, being responsible for 30 million that of ADRENALINE, tyramine occurs in mistle-
cases with a mortality of 10 per cent. Now only toe, mature cheese, beers, red wine and decay-
10,00020,000 cases occur a year, with around ing animal matter. This adrenaline effect is
a few hundred deaths. Efficient rat control is potentially dangerous for patients taking
another measure which reduces the risk of MONOAMINE OXIDASE INHIBITORS (MAOIS)
typhus very considerably. In areas such as ANTIDEPRESSANT DRUGS because, when
Malaysia, where the mites are infected from a combined with tyramine, the blood pressure
wide variety of rodents scattered over large rises sharply. Such patients should avoid taking
areas, the wearing of protective clothing is the cheese, beers and red wine.
most practical method of prophylaxis.
CURATIVE TREATMENT was revolutionised by Tyrosine
the introduction of CHLORAMPHENICOL and One of the AMINO ACIDS. Tyrosine is important
the TETRACYCLINES. These antibiotics altered in the production of CATECHOLAMINES,
the prognosis in typhus fever very considerably. MELANIN and THYROXINE.

T
 tocks, heels and other pressure-points clean and

U dry, and regularly changing his or her position.

If ulcers do develop, repeated local DEBRIDE-
MENT, protective dressings and (in serious
cases) surgical treatment are required, accom-
panied by an appropriate antibiotic if infection
is persistent.
UKCC
United Kingdom Central Council for Nursing, Venous ulcer This occurs on the lower leg
Midwifery and Health Visiting, now known as or ankle and is caused by chronic HYPERTEN-
the Council for Nursing and Midwifery. (See SION in the deep leg VEINS, usually the con-
APPENDIX 7: STATUTORY ORGANISATIONS.) sequences of previous deep vein thrombosis
(DVT) see THROMBOSIS; VEINS, DISEASES OF
UKTSSA which has destroyed the valvular system in the
United Kingdom Transplant Support Service vein(s). The ulcer is usually preceded by
Authority (see TRANSPLANT SUPPORT SERVICES chronic OEDEMA, often local eczema (see
AUTHORITY). DERMATITIS), and bleeding into the skin that
produces brown staining. Varicose veins may or
Ulcer may not be present. Control of the oedema by
Destruction of the skins surface tissues result- compression and encouragement to walk is
ing in an open sore. A similar breach may central to management.
occur in the surface of the mucous membrane
lining body cavities for example, the stom- Ulcerative Colitis
ach, duodenum or colon (see COLITIS). Usu- Chronic inflammation of the lining of the
ally accompanied by pain and local inflamma- COLON and RECTUM. The disease affects
tion, ulcers can be shallow or deep, with a around 50 people per 100,000; it is predomin-
crater-like shape. An ulcer may heal naturally, antly a disease of young and middle-aged
but on certain parts of the body legs (ven- adults.
ous ulcers, see below) or bony protuberances
(decubitus ulcers, see below) they can become Symptoms The onset may be sudden or
chronic and difficult to treat. When an ulcer insidious. In the acute form there is severe diar-
heals, granulations (well-vascularised connect- rhoea and the patient may pass up to 20 stools a
ive tissue) form which become fibrous and day. The stools, which may be small in quantity,
draw the edges of the ulcer together. Any are fluid and contain blood, pus and mucus.
damage to the body surface may develop into There is always fever, which runs an irregular
an ulcer if the causative agent is allowed to course. In other cases the patient first notices
persist for example, contact with a noxious some irregularity of the movement of the
substance or constant pressure on an area of bowels, with the passage of blood. This
tissue with poor circulation. Treatment of skin becomes gradually more marked. There may be
ulcers is effected by cleaning the area, regular pain but usually a varying amount of abdom-
dry dressings and local or systemic ANTI- inal discomfort. The constant diarrhoea leads
BIOTICS depending upon the severity of the to emaciation, weakness and ANAEMIA. As a rule
ulcer. the acute phase passes into a chronic stage. The
chronic form is liable to run a prolonged
Decubitus ulcer Also known as pressure or course, and most patients suffer relapses
bed sore. Occurs when there is constant pres- for many years. SIGMOIDOSCOPY, BIOPSY
sure on and inadequate oxygenation of an area and abdominal X-RAYS are essential diagnostic
of skin, usually overlying a bony protuberance. procedures.
Elderly or infirm people, or individuals with
debilitating, emaciating or neurological ill- Treatment Many patients may be under-
nesses, are vulnerable to the condition. Long- nourished and need expert dietary assessment
term pressure from a bed, wheelchair, cast or and appropriate calorie, protein, vitamin and
splint is the usual cause. Loss of skin sensation mineral supplements. This is particularly
is a contributory factor, and muscle and bone as important in children with the disorder. While
well as skin may be affected. specific nutritional treatment can initiate
improvement in CROHNS DISEASE, this is not
Treatment The most important treatment is the case with ulcerative colitis. CORTICO-
prevention, keeping the patients back, but- STEROIDS, given by mouth or ENEMA, help to
 Ultrasound 739

control the diarrhoea. Intravenous nutrition the muscles that move the fingers and thumb
may be required. The anaemia is treated with and conveys sensation from the fifth and part of
iron supplements, and with blood infusions if the fourth and from the adjacent palm. Muscle
necessary. Blood cultures should be taken, weakness and numbness in the areas supplied
repeatedly if the fever persists. If SEPTICAEMIA is by the nerve is usually caused by pressure from
suspected, broad-spectrum antibiotics should an abnormal outgrowth from the epicondyle at
be given. Surgery to remove part of the affected the bottom of the humerus (upper-arm bone).
colon may be necessary and an ILEOSTOMY is
sometimes required. After recovery, the patient Ultrafiltration
should remain on a low-residue diet, with regu- Filtration carried out under pressure. Blood
lar follow-up by the physician, Mesalazine and undergoes ultrafiltration in the KIDNEYS to
SULFASALAZINE are helpful in the prevention of remove the waste products, urea and surplus
recurrences. water that constitute URINE.
Patients and their relatives can obtain help
and advice from the National Association for Ultrasonography
Colitis and Crohns Disease. The use of ULTRASOUND to produce images of
structures in the body that can be viewed on a
Ulcer Healing Drugs television screen and transferred to photo-
A variety of drugs with differing actions are graphic film.
available for the treatment of peptic ulcer, the
composite title covering gastric ulcer (see STOM- Ultrasound
ACH, DISEASES OF) and DUODENAL ULCER. Pep- Ultrasound, or ultrasonic, waves comprise
tic ulceration may also involve the lower very-high-frequency sound waves above
OESOPHAGUS, and after stomach surgery the 20,000 Hz that the human ear cannot hear.
junction of the stomach and small intestine. Ultrasound is widely used for diagnosis and
The drugs used in combination are: also for some treatments. In OBSTETRICS,
The receptor antagonists, which reduce the
output of gastric acid by histamine H2-
ultrasound can assess the stage of pregnancy
and detect abnormalities in the FETUS (see
receptor blockade; they include CIMETIDINE, below). It is a valuable adjunct in the investiga-
FAMOTIDINE and RANITIDINE. tion of diseases in the bladder, kidneys, liver,
ANTIBIOTICS to eradicate Helicobacter pylori ovaries, pancreas and brain (for more informa-
infection, a major cause of peptic ulceration. tion on these organs and their diseases, see
They are usually used in combination with under separate entries); it also detects thromboses
one of the PROTON-PUMP INHIBITORS and (clots) in blood vessels and enables their
include clarithomycin, amoxacillin and extent to be assessed. A non-invasive tech-
metronidazole. nique that does not need ionising radiation,
BISMUTH chelates. ultrasound is quick, versatile and relatively
The prostaglandin analogue misoprostol has
antisecretory and protective properties.
inexpensive, with scans being done in any
plane of the body. There is little danger to the
Proton-pump inhibitors omeprazole, lanso- patient or operator: unlike, for example, X-
prazole, pantaprazole and rabeprazole, all of RAYS, ultrasound investigations can be
which inhibit gastric-acid secretion by block- repeated as needed. A contrast medium is not
ing the proton pump enzyme system. required. Its reliability is dependent upon the
skill of the operator.
Ulna Ultrasound is replacing ISOTOPE scanning in
The inner of the two bones in the forearm. It is many situations, and also RADIOGRAPHY. Ultra-
wide at its upper end, and its olecranon process sound of the liver can separate medical from
U
forms the point of the elbow. In its lower part it surgical JAUNDICE in approximately 97 per cent
is more fragile and liable to be broken by a fall of patients; it is very accurate in detecting and
upon the forearm while something is grasped in defining cystic lesions of the liver, but is less
the hand. Chipping-off of the olecranon pro- accurate with solid lesions and yet will detect
cess is a not uncommon result of falls upon the 85 per cent of secondary deposits (this is less
elbow. (See BONE, DISORDERS OF Bone than COMPUTED TOMOGRAPHY [CT] scan-
fractures.) ning). It is very accurate in detecting gall-stones
(see GALL-BLADDER, DISEASES OF) and more
Ulnar Nerve accurate than the oral cholecystogram. It is use-
A major NERVE in the arm, it runs from the ful as a screening test for pancreatic disease and
brachial plexus to the hand. The nerve controls can differentiate carcinoma of the pancreas
 740 Ultraviolet Rays (UVR)

from chronic pancreatitis with 85 per cent the reduced blood flow through narrowed
accuracy. vessels.
Ultrasound is the first investigation indi-
cated in patients presenting with renal failure, Ultrasound in obstetrics Ultrasound has
as it can quickly determine the size and shape particular applications in obstetrics. A fetus can
of the kidney and whether there is any obstruc- be seen with ultrasound from the seventh week
tion to the URETER. It is very sensitive to the of pregnancy, and the fetal heart can be demon-
presence of dilatation of the renal tract and will strated at this stage. Multiple pregnancy can
detect space-occupying lesions, differentiating also be diagnosed at this time by the demonstra-
cysts and tumours. It can detect also obstruc- tion of more than one gestation sac containing
tion of the ureter due to renal stones by show- a viable fetus. A routine obstetric scan is usually
ing dilatations of the collecting system and the performed between the 16th and 18th week of
presence of the calculus. Adrenal (see ADRENAL pregnancy when the fetus is easily demon-
GLANDS) tumours can be demonstrated by strated and most photogenic. The fetus can be
ultrasound, although it is less accurate than CT measured to assess the gestational age, and the
scanning. anatomy can also be checked. Intra-uterine
The procedure is now the first test for sus- growth retardation is much more reliably diag-
pected aortic ANEURYSM and it can also show nosed by ultrasound than by clinical assess-
the presence of clot and delineate the true and ment. The site of the placenta can also be
false lumen. It is good at demonstrating sub- recorded and multiple pregnancies will be diag-
phrenic and subhepatic abscesses (see ABSCESS) nosed at this stage. Fetal movements and even
and will show most intra-abdominal abscesses; the heartbeat can be seen. A second scan is
CT scanning is however better for the retro- often done between the 32nd and 34th weeks
peritoneal region. It has a major application in to assess the position, size and growth rate of
thyroid nodules as it can differentiate cystic the baby. The resolution of equipment now
from solid lesions and show the multiple lesions available enables pre-natal diagnosis of a wide
characteristic of the nodular GOITRE (see also range of structural abnormalities to be diag-
THYROID GLAND, DISEASES OF). It cannot dif- nosed. SPINA BIFIDA, HYDROCEPHALUS and
ferentiate between a follicular adenoma and a ANENCEPHALY are probably the most import-
carcinoma, as both these tumours are solid; nor ant, but other anomalies such as multicystic
can it demonstrate normal parathyroid glands. kidney, achondroplasia and certain congenital
However, it can identify adenomas provided cardiac anomalies can also be identified. Fetal
that they are more than 6 mm in diameter. gender can be determined from 20 weeks of
Finally, ultrasound can differentiate masses in gestation. Ultrasound is also useful as guidance
the SCROTUM into testicular and appendicular, for AMNIOCENTESIS.
and it can demonstrate impalpable testicular In gynaecology, POLYCYSTIC OVARY SYN-
tumours. This is important as 15 per cent of DROME can readily be detected as well as
testicular tumours metastasise whilst they are FIBROID and ovarian cysts. Ultrasound can
still impalpable. monitor follicular growth when patients are
Ultrasonic waves are one of the constituents being treated with infertility drugs. It is also
in the shock treatment of certain types of gall- useful in detecting ECTOPIC PREGNANCY. (See
stones and CALCULI in the urinary tract (see also PREGNANCY AND LABOUR.)
LITHOTRIPSY). They are also being used in the
treatment of MENIRES DISEASE and of Ultraviolet Rays (UVR)
bruises and strains. In this field of physio- Invisible light rays of very short wavelength
therapy, ultrasonic therapy is proving of par- beyond the violet end of the suns spectrum.
U ticular value in the treatment of acute injuries Ultraviolet-C (UVC) (wavelength <290 nm
of soft tissue. If in such cases it is used immedi- [nanometre see APPENDIX 6: MEASUREMENTS
ately after the injury, or as soon as possible IN MEDICINE]) is entirely absorbed by the
thereafter, prompt recovery is facilitated. For earths atmosphere and would otherwise be
this reason it is being widely used in the treat- lethally damaging. Ultraviolet-B (UVB 290
ment of sports injuries (see also SPORTS MEDI- 320 nm) intensity increases with altitude: it is
CINE). The sound waves stimulate the healing greatest in midsummer and at midday and
process in damaged tissue. penetrates cirrhus cloud. UVB causes sunburn
and also tanning. Ultraviolet-A (UVA 320
Doppler ultrasound is a technique which 400 nm) penetrates deeper into our skins but
shows the presence of vascular disease in the does not cause sunburn; it is implicated in
carotid and peripheral vessels, as it can detect many photochemical reactions and PHOTO-
 Unconsciousness 741

DERMATOSES and in CARCINOGENESIS. UVR disorders such as URAEMIA or toxic disorders

helps the skin to synthesise vitamin D. such as SEPTICAEMIA; direct effects on the brain
Ultraviolet lamps produce UVR and are used stem as a result of infective, cancerous or trau-
to tan skin but, because of the risk of producing matic lesions; and indirect effects on the brain
skin cancer (see SKIN, DISEASES OF), the lamps stem such as a tumour or OEDEMA in the cere-
must be used with great caution. brum creating pressure within the skull. Within
these three divisions are a large number of spe-
Umbilical Cord cific causes of unconsciousness.
The fleshy tube containing two arteries and a Unconsciousness may be temporary, pro-
vein through which the mother supplies the longed or indefinite (see PERSISTENT VEGETA-
FETUS with oxygen and nutrients. The cord, TIVE STATE (PVS)), depending upon the severity
which is up to 60 cm long, ceases to function of the initiating incident. The patients recovery
after birth and is clamped and cut about 25 cm depends upon the cause and success of treat-
from the infants abdominal wall. The stump ment, where given. MEMORY may be affected, as
shrivels and falls off within two weeks, leaving a may motor and sensory functions; but short
scar which forms the UMBILICUS. (See also PREG- periods of unconsciousness as a result, say, of
NANCY AND LABOUR.) trauma have little obvious effect on brain func-
tion. Repeated bouts of unconsciousness
Umbilicus (which can happen in boxing) may, however,
The scientific name for the navel, a circular have a cumulatively damaging effect, as can be
depression in the ABDOMEN that marks the seen on CT (COMPUTED TOMOGRAPHY) scans
areas where the UMBILICAL CORD was attached of the brain.
when the fetus was in the uterus. POISONS such as CARBON MONOXIDE (CO),
drug overdose, a fall in the oxygen content of
Uncinate Fit blood (HYPOXIA) in lung or heart disease, or
A type of temporal lobe EPILEPSY in which a liver or kidney failure harm the normal chem-
patient has a hallucination of smell or of taste; it ical working or metabolism of nerve cells.
may also be the result of a tumour pressing on Severe blood loss will cause ANOXIA of the
that part of the BRAIN concerned with the brain. Any of these can result in altered brain
appreciation of smell and taste. function in which impairment of consciousness
is a vital sign.
Unconscious Sudden altered consciousness will also result
A state of UNCONSCIOUSNESS or a description from fainting attacks (syncope) in which the
of mental activities of which an individual is blood pressure falls and the circulation of oxy-
unaware. The term is also used in PSYCHO- gen is thereby reduced. Similarly an epileptic fit
ANALYSIS to characterise that section of a causes partial or complete loss of consciousness
persons mind in which memories and motives by causing an abrupt but temporary disruption
reside. They are normally inaccessible, pro- of the electrical activity in the nerve cells in the
tected by inbuilt mental resistance. This con- brain (see EPILEPSY).
trasts with the subconscious, where a persons In these events, as the brains function pro-
memories and motives while temporarily gressively fails, drowsiness, stupor and finally
suppressed can usually be recalled. COMA ensue. If the cause is removed (or when
the patient spontaneously recovers from a fit or
Unconsciousness faint), normal consciousness is usually quickly
The BRAIN is the organ of the mind. Normal regained. Strokes (see STROKE) are sometimes
conscious alertness depends upon its continu- accompanied by a loss of consciousness; this
ous adequate supply with oxygen and glucose, may be immediate or come on slowly, depend-
U
both of which are essential for the brain cells to ing upon the cause or site of the strokes.
function normally. If either or both of these are Comatose patients are graded according to
interrupted, altered consciousness results. Inter- agreed test scales for example, the GLASGOW
ruption may be caused by three broad types of COMA SCALE in which the patients response
process affecting the brain stem: the reticular to a series of tests indicate numerically the level
formation (a network of nerve pathways and of coma.
nuclei-connecting sensory and motor nerves to Treatment of unconscious patients depends
and from the cerebrum, cerebellum, SPINAL upon the cause, and range from first-aid care for
CORD and cranial nerves) and the cerebral someone who has fainted to hospital intensive-
cortex. The three types are diffuse brain dys- care treatment for a victim of a severe head
function for example, generalised metabolic injury or massive stroke.
 742 Undescended Testis

Undescended Testis tubules of the kidney or it may result from

See under TESTICLE, DISEASES OF. obstruction to the outflow of URINE.
The word uraemia means excess UREA in
Undulant Fever the blood; however, the symptoms of renal
Another name for BRUCELLOSIS. failure are not due to the abnormal amounts
of urea circulating, but rather to the electro-
Ungual lyte disturbances (see ELECTROLYTES) and
An adjective relating to the fingernails or ACIDOSIS which are associated with impaired
toenails. renal function. The acidosis results from a
decreased ability to filter hydrogen ions from
Unguentum blood into the glomerular fluid: the reduced
The Latin name for ointment. production of ammonia and phosphate means
fewer ions capable of combining with the
Unit hydrogen ions, so that the total acid elimin-
The term applied to a quantity assumed as a ation is diminished. The fall in glomerular
standard for measurement. Thus, the unit of filtration also leads to retention of SODIUM
insulin is the specific activity contained in such and water with resulting OEDEMA, and to
an amount of the standard preparation as the retention of POTASSIUM resulting in
Medical Research Council may from time to HYPERKALAEMIA.
time indicate as the quantity exactly equivalent The most important causes of uraemia are
to the unit accepted for international use. The the primary renal diseases of chronic glomerular
standard preparation consists of pure, dry, crys- nephritis (inflammation) and chronic
talline insulin. (See APPENDIX 6: MEASUREMENTS PYELONEPHRITIS. It may also result from
IN MEDICINE.) MALIGNANT HYPERTENSION damaging the kid-
neys and amyloid disease destroying them.
Upper Limb Disorders Analgesic abuse can cause tubular necrosis.
A group of injuries resulting from overuse of a DIABETES MELLITUS may cause a nephropathy
part of the limb. One example is TENNIS ELBOW and lead to uraemia, as may MYELOMATOSIS
(epicondylitis) caused by inflammation of the and SYSTEMIC LUPUS ERYTHEMATOSUS (SLE).
tendon attaching the extensor muscles of the Polycystic kidneys and renal tuberculosis
forearm to the humerus because of overuse of account for a small proportion of cases.
the muscles. Overuse of the shoulder muscles
may cause inflammation and pain around the Symptoms Uraemia is sometimes classed as
joint. Perhaps the best-known example is acute that is, those cases in which the symp-
repetitive strain injury (RSI) affecting keyboard toms develop in a few hours or days and
workers and musicians: the result is pain in and chronic, including cases in which the symptoms
weakness of the wrists and fingers. This has are less marked and last over weeks, months, or
affected thousands of people and been the sub- years. There is, however, no dividing line
ject of litigation by employees against their between the two, for in the chronic variety,
employers. Working practices have been which may be said to consist of the symptoms
improved and the complaint is now being rec- of chronic glomerulonephritis, an acute attack
ognised at an early stage. Treatment includes is liable to come on at any time.
PHYSIOTHERAPY, but some sufferers have been Headache in the front or back of the head,
obliged to give up their work. accompanied often by insomnia and daytime
drowsiness, is one of the most common symp-
U Urachus
A corded structure which extends from the
toms. UNCONSCIOUSNESS of a profound type,
which may be accompanied by CONVULSIONS
bladder up to the navel, and represents the resembling those of EPILEPSY, is the most out-
remains of the canal which in the FETUS joins standing feature of an acute attack and is a very
the bladder with the ALLANTOIS. dangerous condition.
Still another symptom, which often precedes
Uraemia an acute attack, is severe vomiting without
The clinical state which results from renal fail- apparent cause. The appetite is always poor, and
ure (see KIDNEYS, DISEASES OF). It may be due to the onset of diarrhoea is a serious sign.
disease of the KIDNEYS or it may be the result of
pre-renal causes where a lack of circulating Treatment The treatment of the chronic
blood volume inadequately perfuses the kid- type of uraemia includes all the measures which
neys. It may result from acute necrosis in the should be taken by a person suffering from
 Urethra, Diseases of and Injury to 743

chronic glomerulonephritis (see under KIDNEYS, Ureteroenterostomy

DISEASES OF). An increasing number of these A surgically produced artificial channel between
patients, especially the younger ones, are treated the URETER and the large bowel (see INTESTINE).
with DIALYSIS and/or renal TRANSPLANTATION. A form of diversion of the URINE flow, the
URINARY BLADDER is bypassed and the ureters
Urates drain into the sigmoid COLON. The operation is
See URIC ACID. done when a bladder is removed, usually
because of cancer.
Urea
Urea, or carbomide, is a crystalline substance
of the chemical formula CO(NH2)2, which is
Ureteroscope
A flexible or rigid endoscopic instrument (see
very soluble in water or alcohol. It is the chief
ENDOSCOPE) that is inserted (via the URINARY
waste product discharged from the body in
BLADDER) into the URETER and up into the
the URINE, being formed in the liver and car-
pelvis of the kidney (see KIDNEYS). The
ried to the kidneys in the blood. The amount
instrument is commonly used to identify a
varies considerably with the quantity and
stone in the ureter and to remove it under
nature of the food taken, rising greatly upon
vision with forceps or a stone basket. If the
an animal (protein) dietary. It also rises during
stone is large it is broken into fragments,
the continuance of a fever. The average
using an ultrasound or electrohydraulic
amount excreted daily by a healthy adult on a
LITHOTRIPSY probe that is inserted through
mixed diet is about 3335 grams. Kidney fail-
the instrument.
ure causes a rise in the concentration of urea
in the blood (see URAEMIA; KIDNEYS, DISEASES
OF). Urethra
Urea is usually administered for its diuretic The tube which leads from the URINARY
action (see DIURETICS), and also as a test of kid- BLADDER to the exterior, and by which the
ney action, in doses of 515 grams. It is used, URINE is voided. It is about 20 cm (8 inches)
too, as a cream in the treatment of certain skin long in the male and 35 cm (1 inches) long
diseases, characterised by a dry skin. in the female. In the male it passes along the
Urea is rapidly changed, by a yeast-like PENIS; in the female the urethra opens to the
micro-organism, into carbonate of ammonia exterior just in front of the VAGINA between
the cause of the ammoniacal smell associated the labial folds.
with INCONTINENCE and inadequately cleaned
toilets. Urethra, Diseases of and
Injury to
Ureaplasma
A group of micro-organisms which plays a Trauma Injury to the urethra is often the
larger part in the causation of disease than was result of severe trauma to the pelvis for
at one time suspected. One of them, Urea- example, in a car accident or as the result of a
plasma urealyticum, is now recognised as a cause fall. Trauma can also result from catheter inser-
of chronic prostatitis (see under PROSTATE tion (see CATHETERS) or the insertion of foreign
GLAND, DISEASES OF), NON-SPECIFIC URETH- bodies into the urethra. The signs are the
RITIS (NSU) see also URETHRA, DISEASES OF AND inability to pass urine, and blood at the exit of
INJURY TO and INFERTILITY. the urethra. The major complication of trauma
is the development of a urethral stricture (see
Ureter below). U
The tube that carries URINE from the kidney (see
KIDNEYS) to the URINARY BLADDER. There are
two ureters, one for each kidney, and they ori- Urethritis is inflammation of the urethra
ginate from the kidney pelvis and track for 25 from infection.
30 cm (1012 inches) through the loins and
pelvis. They open by a narrow slit into the base Causes The sexually transmitted disease
of the bladder. The lower end of the ureter GONORRHOEA affects the urethra, mainly in
pierces the wall of the bladder so obliquely men, and causes severe inflammation and
(lying embedded in the wall for about 21 mm) urethritis. Non-specific urethritis (NSU) is an
that, although urine runs freely into the blad- inflammation of the urethra caused by one of
der, it is prevented from returning up the ureter many different micro-organisms including
as the bladder becomes distended. BACTERIA, YEAST and CHLAMYDIA.
 744 Urethral Syndrome

Symptoms The classic signs and symptoms woman strains to urinate or defaecate, or dur-
are a urethral discharge associated with urethral ing childbirth. The condition is usually the
pain, particularly on micturition (passing consequence of a previous pregnancy. The con-
urine), and DYSURIA. dition is treated with surgical repair of the slack
tissues to strengthen support for the urethra
Treatment This involves taking urethral and vaginal wall.
swabs, culturing the causative organism and
treating it with the appropriate antibiotic. The Urethrography
complications of urethritis include stricture Examination of the URETHRA using X-RAYS. A
formation. radio-opaque fluid is injected into the bladder
and any abnormalities of the urethra can be
Stricture This is an abrupt narrowing of the observed on the X-ray films.
urethra at one or more places. Strictures can be
a result of trauma or infection or a congenital Urethroplasty
abnormality from birth. Rarely, tumours can Surgical repair of the URETHRA, usually to
cause strictures. relieve a stricture (see under URETHRA, DISEASES
OF AND INJURY TO).
Symptoms The usual presenting complaint is
one of a slow urinary stream. Other symptoms Uric Acid
include hesitancy of micturition, variable A crystalline substance, very slightly soluble in
stream and terminal dribbling. Measurement of water, of chemical formula, C5N4H4O3. The
the urine flow rate may help in the diagnosis, average daily quantity of uric acid passed by
but often strictures are detected during cyst- human beings is 051 gram. It is formed in the
oscopy (see CYSTOSCOPE). LIVER from the breakdown products of proteins
and removed by the KIDNEYS from the blood.
Treatment The traditional treatment was the The amount is increased in the following
periodic dilation of the strictures with sounds conditions:
solid metal rods passed into the urethra. Excessive consumption of meat, combined
However, a more permanent solution is with sedentary habits.
achieved by cutting the stricture with an endo- GOUT.
scopic knife (optical urethrotomy). For more Diseases in which the white corpuscles of
complicated long or multiple strictures, an the blood are increased: for example,
open operation (urethroplasty) is required. LEUKAEMIA.
The bi-urate of sodium and urate of ammo-
Urethral Syndrome nium occur in considerable amounts in the
A group of symptoms of unknown cause. It URINE during a feverish state or after great
mainly affects women, and occasionally men, exertion, and produce, as the urine cools, a
with pain and discomfort in the lower abdo- dense pink or yellow sediment. Owing to
men, a frequent urge to urinate and, in women, their insolubility, uric acid and the various
pain in the area of the VULVA. Investigation urates often produce deposits in the urinary
rarely results in any abnormal findings. Post- passages, which are known as urinary sand,
menopausal women (see MENOPAUSE), who are gravel, or stones according to their size.
the most common sufferers, may have inflam-
mation of the vulva due to thinning of the tis- Uricosuric Drug
sues in that area. Treatment is supportive, with A drug that increases the amount of URIC ACID
the patient being advised to drink a lot of fluid excreted in the URINE. Among the drugs used
U and maintain a high standard of personal are PROBENECID or a sulfa derivative. Uricosu-
hygiene. rics are used to treat GOUT and other disorders
which cause raised blood-uric-acid
Urethritis concentrations.
Urethritis means inflammation of the URETHRA
(see NON-SPECIFIC URETHRITIS (NSU); URETHRA, Urinalysis
DISEASES OF AND INJURY TO). Analysis of the physical and chemical com-
position of URINE to detect variations in the
Urethrocele substances normally present, and to identify
PROLAPSE of the URETHRA into the wall of the any abnormal constituents such as sugar, blood,
VAGINA. The result is a bulbous swelling in drugs or alcohol. Sugar, protein and blood can
the roof of the vagina which is worse when the be identified using chemically impregnated dip-
 Urinary Diversion 745

sticks which change colour in the presence of bacterial growth, and an appropriate course of
these substances. The presence of microscopic ANTIBIOTICS once a urine sample has been ana-
HAEMATURIA (blood in the urine) should be lysed in the laboratory to confirm the diagnosis
confirmed by microscopic examination of a and determine what antibiotics the causative
fresh, midstream urine specimen. The specimen organism is likely to respond to.
should also be sent for bacteriological culture to
exclude or identify infection. If protein in the Stone or calculus The usual reason for the
urine is suspected, a 24-hour collection of urine formation of a bladder stone is an obstruction
should be assessed. Cytological examination to the bladder outflow, which results in stag-
will identify abnormal or malignant cells in the nant residual urine ideal conditions for the
urinary tract. crystallisation of the chemicals that form stones
or from long-term indwelling CATHETERS
Urinary Bladder which weaken the natural mechanical protec-
The urinary bladder is a highly distensible tion against bacterial entry and, by bruising the
organ for storing URINE. It consists of smooth lining tissues, encourage infection.
muscle known as the detrusor muscle and is
lined with urine-proof cells known as Symptoms The classic symptom is a stoppage
transitional cell epithelium. in the flow of urine during urination, associated
The bladder lies in the anterior half of the with severe pain and the passage of blood.
PELVIS, bordered in front by the pubis bone and
laterally by the side wall of the pelvis. Superiorly Treatment This involves surgical removal of
the bladder is covered by the peritoneal lining the stone either endoscopically (litholapaxy); by
of the abdomen. The bottom or base of the passing a cystoscope into the bladder via the
bladder lies against the PROSTATE GLAND in the urethra and breaking the stone; or by LITHO-
male and the UTERUS and VAGINA in the female. TRIPSY in which the stone (or stones) is des-
troyed by applying ultrasonic shock waves. If
Urinary Bladder, Diseases of the stone cannot be destroyed by these
Diseases of the URINARY BLADDER are diag- methods, the bladder is opened and the stone
nosed by the patients symptoms and signs, removed (cystolithotomy).
examination of the URINE, and using investiga-
tions such as X-RAYS and ULTRASOUND scans. Cancer Cancer of the bladder accounts for 7
The interior of the bladder can be examined per cent of all cancers in men and 25 per cent
using a cystoscope, which is a fibreoptic endo- in women. The incidence increases with age,
scope (see FIBREOPTIC ENDOSCOPY) that is with smoking and with exposure to the indus-
passed into the bladder via the URETHRA. trial chemicals, beta-napththylamine and ben-
zidine. In 2003, 2,884 men and 1,507 women
Cystitis Most cases of cystitis are caused by died of bladder cancer in England and Wales.
bacteria which have spread from the bowel,
especially Escherichia coli, and entered the blad- Symptoms The classical presenting symptom
der via the urethra. Females are more prone to of a bladder cancer is the painless passing of
cystitis than are males, owing to their shorter blood in the urine haematuria. All patients
urethra which allows easier entry for bacteria. with haematuria must be investigated with an
Chronic or recurrent cystitis may result in X-ray of their kidneys, an INTRAVENOUS
infection spreading up the ureter to the kidney PYELOGRAM (UROGRAM) and a cystoscopy.
(see KIDNEY, DISEASES OF).
Treatment Superficial bladder tumours on U
Symptoms Typically there is frequency and the lining of the bladder can be treated by local
urgency of MICTURITION, with stinging and removal via the cystoscope using DIATHERMY
burning on passing urine (dysuria), which is (cystodiathermy). Invasive cancers into the
often smelly or bloodstained. In severe infection bladder muscle are usually treated with RADIO-
patients develop fever and rigors, or loin pain. THERAPY, systemic CHEMOTHERAPY or surgical
Before starting treatment a urine sample should removal of the bladder (cystectomy). Local
be obtained for laboratory testing, including chemotherapy may be useful in some patients
identification of the invading bacteria. with multiple small tumours.

Treatment This includes an increased fluid Urinary Diversion

intake, ANALGESICS, doses of potassium citrate One of a variety of procedures for collecting
to make the urine alkaline to discourage and diverting URINE from its customary
 746 Urinary Tract

channel of excretion following surgical removal amber-coloured, but may be changed by vari-
of the bladder for disease, usually cancer. The ous diseases or drugs. Chronic glomerulone-
ureters (see URETER) may be implanted in the phritis or poorly controlled diabetes may lead to
large bowel, or a reservoir or small pouch may a watery appearance, as may drinking large
be fashioned using a section of small or large amounts of water. Consumption of beetroot or
INTESTINE. In the latter method the pouch is rhubarb may lead to an orange or red colour,
emptied through a small STOMA using a cath- while passage of blood in the urine (haem-
eter (see CATHETERS), thus dispensing with the aturia) results in a pink or bright red appear-
need for a urinary drainage bag. ance, or a smoky tint if just small amounts are
passed. A greenish urine is usually due to BILE,
Urinary Tract or may be produced by taking QUININE.
A collective name for the KIDNEYS, ureters (see Healthy urine has a faint aroma, but gives off
URETER), URINARY BLADDER and URETHRA, an unpleasant ammoniacal smell when it begins
which between them produce, collect and void to decompose, as may occur in urinary infec-
URINE. tions. Many foods and additives give urine a
distinctive odour; garlic is particularly charac-
Urination teristic. The density or specific gravity of urine
The act of voiding URINE through the varies normally from 1,015 to 1,025: a low
URETHRA. Abnormalities in urination such as value suggests chronic glomerulonephritis,
difficulty in starting or stopping, greater than while a high value may occur in uncontrolled
normal frequency, unusually small amounts of diabetes or during fevers. Urine is normally
urine passed, a constant feeling of wanting to acidic, which has an important antiseptic
urinate or a sudden hard-to-control urge to action; it may at times become alkaline, how-
urinate are all symptoms that suggest possible ever, and in vegetarians, owing to the large
disorders of the urinary tract which merit dietary consumption of alkaline salts, it is
investigation. permanently alkaline.
Chemical or microscopical examination of
Urine the urine is necessary to reveal abnormal drugs,
Waste substances resulting from the bodys poisons, or micro-organisms. There are six sub-
metabolic processes, selected by the KIDNEYS stances which must be easily detectable for
from the blood, dissolved in water, and diagnostic purposes: these are ALBUMINS,
excreted. Urine is around 96 per cent water, the blood, GLUCOSE, bile, ACETONE, and PUS and
chief waste substances being UREA (approxi- tube-casts (casts from the lining of the tubules
mately 25 g/1), common salt (approximately 9 in the kidneys). Easily used strip tests are avail-
g/l), and phosphates and sulphates of potas- able for all of these, except the last.
sium, sodium, calcium, and magnesium. There
are also small amounts of URIC ACID, ammonia, Excess of urine It is important to dis-
creatinine, and various pigments. Poisons, such tinguish urinary frequency from increase in the
as MORPHINE, may be excreted in the urine; and total amount of urine passed. Frequency may be
in many infections, such as typhoid fever (see due to reduced bladder capacity, such as may be
ENTERIC FEVER), the causative organism may be caused by an enlarged PROSTATE GLAND, or due
excreted. to any irritation or infection of the kidneys or
The daily urine output varies, but averages bladder, such as CYSTITIS or the formation of a
around 1,500 ml in adults, less in children. The stone. Increased total urinary output, on the
fluid intake and fluid output (urine and PER- other hand, is often a diagnostic feature of dia-
SPIRATION) are interdependent, so as to main- betes mellitus. Involuntary passage of urine at
U tain a relatively constant fluid balance. Urine night may result, leading to bed wetting, or
output is increased in certain diseases, notably NOCTURNAL ENURESIS in children. Diagnosis
DIABETES MELLITUS; it is diminished (or even of either condition, therefore, means that the
temporarily stopped) in acute glomerulonephri- urine should be tested for glucose, albumin,
tis (see under KIDNEYS, DISEASES OF), heart fail- gravel (fragments of urinary calculi), and pus,
ure, and fevers generally. Failure of the kidneys with appropriate treatment.
to secrete any urine is known as anuria, while
stoppage due to obstruction of the ureters (see Urine Retention
URETER) by stones, or of the URETHRA by a This occurs when URINE is produced by the
stricture, despite normal urinary secretion, is kidneys but not voided by the bladder. It is gen-
known as urinary retention. erally less serious than ANURIA, in which urine
Normal urine is described as straw- to is not produced.
 Urticaria 747

Causes Neurological injury, such as trauma Urography

to the spinal cord, may cause bladder weakness, Examination of the URINARY TRACT by means
leading to retention, although this is rare. of contrast medium X-rays (see PYELOGRAPHY;
Obstruction to outflow is more common: this URETHROGRAPHY).
may be acute and temporary, for example after
childbirth or following surgery for piles Urokinase
(HAEMORRHOIDS); or chronic, for example, Urokinase is an ENZYME obtained from URINE
with prostatic enlargement (see PROSTATE which dissolves blood clots. It is used to treat
GLAND). Commonly seen in elderly men, this THROMBOLYSIS in the EYE, in arteriovenous
leads to reduced bladder capacity, with partial shunts (see SHUNT) and deep-vein THROMBOSIS.
emptying every few hours. Total retention is It has the advantage over other fibrinolytic
rare, but may result from a stricture, or narrow- drugs of not causing immunological reactions.
ing, of the URETHRA (see also URETHRA, DISEASES
OF AND INJURY TO) usually the result of infec- Urology
tion or injury or to pressure from a large The branch of medicine which treats disorders
neighbouring tumour. and diseases of the KIDNEYS, ureters (see
Retention is generally treated by regular use URETER), URINARY BLADDER, PROSTATE
of a urethral catether (see CATHETERS), various GLAND, and URETHRA.
types of which are available. Tapping of the
bladder with a needle passed above the pubis is Ursodeoxycholic Acid
rarely necessary, but may occasionally be A preparation used in the treatment of choles-
required in cases of severe stricture. terol gall-stones when laparoscopic CHOLECYS-
TECTOMY and endoscopic biliary procedures
Urinometer cannot be used (see GALL-BLADDER, DISEASES
A simple instrument designed for estimating OF).
the specific gravity of URINE a test that can be
helpful in diagnosing disorders of the URINARY URTI
TRACT. An abbreviation for upper respiratory tract
infection that is colds (see COMMON COLD),
Urobilinogen otitis media (see EAR, DISEASES OF Diseases of
A chemical compound formed when bacteria in the middle ear), TONSILLITIS, PHARYNGITIS and
the intestine act on BILIRUBIN. Some is laryngo-tracheo-bronchitis (see CROUP; LARYNX,
reabsorbed and returns to the LIVER and some is DISORDERS OF).
eliminated in the faeces.
Urticaria
Urocele The rash produced by the sudden release of
A cystic swelling that develops in the SCROTUM HISTAMINE in the skin. It is characterised by
when URINE escapes from the URETHRA, usu- acute itching, redness and wealing which sub-
ally after injury. Prompt treatment is necessary sides within a few minutes or may persist for a
and this is done by diverting the urine by day or more. Depending upon the cause, it may
inserting a suprapubic catheter (see CATHETERS) be localised or widespread and transient or con-
into the URINARY BLADDER, draining the stantly recurrent over years. It has many causes.
cystocele and giving the patients antibiotics.
The injured urethra can be surgically repaired External injuries to the skin such as the
later. sting of a nettle (nettle-rash) or an insect bite
cause histamine release from MAST CELLS in the
Urodynamics skin directly. Certain drugs, especially MOR-
U
The measurement of the pressures within the PHINE, CODEINE and ASPIRIN, can have the
URINARY BLADDER as well as the pressures of the same effect. In other cases, histamine release is
urethral sphincter. The technique is useful in caused by an allergic mechanism, mediated by
the investigation of patients with urinary ANTIBODIES of the immunoglobulin E (IgE)
incontinence. Special equipment is needed to class see IMMUNOGLOBULINS. Thus many
carry out the procedure. foods, food additives and drugs (such as PENI-
CILLIN) can cause urticaria. Massive release of
Urogenital histamine may affect mucous membranes
An adjective relating to the organs and tissues namely the tongue or throat and can cause
involved in the anatomically closely related HYPOTENSION and anaphylactic shock (see ANA-
functions of excretion and reproduction. PHYLAXIS) which can occasionally be fatal.
 748 Uterus

Physical factors can cause urticaria. Heat, becomes embedded and in which the EMBRYO
exercise and emotional stress may induce a sin- and FETUS develop. The normal uterus weighs
gular pattern with small pinhead weals, but 3040 g; during pregnancy, however, enormous
widespread flares of ERYTHEMA, activated via growth occurs together with muscular thicken-
the AUTONOMIC NERVOUS SYSTEM (CHOLIN- ing (see MUSCLE Development of muscle).
ERGIC urticaria) may also occur. The cavity is lined by a thick, soft, mucous
Rarely, exposure to cold may have a smiilar membrane, and the wall is chiefly composed of
effect (cold urticaria) and anaphylactic shock muscle fibres arranged in three layers. The outer
following a dive into cold water in winter is surface, like that of other abdominal organs, is
occasionally fatal. The diagnosis of cold urti- covered by a layer of PERITONEUM. The uterus
caria can be confirmed by applying a block of has a copious supply of blood derived from the
ice to the arm which quickly induces a local uterine and ovarian arteries. It has also many
weal. lymphatic vessels, and its nerves establish wide
Transient urticaria due to rubbing or even connections with other organs (see PAIN). The
stroking the skin is common in young adults position of the uterus is in the centre of the
(DERMOGRAPHISM or factitious urticaria). More PELVIS, where it is suspended by several liga-
prolonged deep pressure induces delayed urti- ments between the URINARY BLADDER in front
caria in other subjects. IgE-mediated urticaria is and the RECTUM behind. On each side of the
part of the atopic spectrum (see ATOPY, and uterus are the broad ligaments passing outwards
SKIN, DISEASES OF Dermatitis and eczema). to the side of the pelvis, the utero-sacral
Allergy to peanuts is particularly dangerous in ligament passing back to the sacral bone, the
young atopic subjects. Notwithstanding the utero-vesical ligament passing forwards to
many known causes, chronic urticaria of the bladder, and the round ligament uniting the
unknown cause is common and may have an uterus to the front of the abdomen.
autoimmune basis (see AUTOIMMUNE
DISORDERS). Uterus, Diseases of
Treatment Causative factors must be Absence or defects of the uterus
removed. Topical therapy is ineffective except Rarely, the UTERUS may be completely absent
for the use of calamine lotion, which reduces as a result of abnormal development. In such
itching by cooling the skin. Oral ANTIHISTA- patients secondary sexual development is nor-
MINES are the mainstay of treatment and are mal but MENSTRUATION is absent (primary
remarkably safe. Rarely, injection of ADRENA- amennorhoea). The chromosomal make-up of
LINE is needed as emergency treatment of the patient must be checked (see CHROMO-
massive urticaria, especially if the tongue and SOMES; GENES): in a few cases the genotype is
throat are involved, following by a short course male (testicular feminisation syndrome). No
of the oral steroid, prednisolone. treatment is available, although the woman
should be counselled.
Angio-oedema is a variant of urticaria The uterus develops as two halves which fuse
where massive OEDEMA involves subcutaneous together. If the fusion is incomplete, a uterine
tissues rather than the skin. It may have many SEPTUM results. Such patients with a double
causes but bee and wasp stings in sensitised sub- uterus (uterus didelphys) may have fertility
jects are particularly dangerous. There is also a problems which can be corrected by surgical
rare hereditary form of angio-oedema. Acute removal of the uterine septum. Very rarely there
airway obstruction due to submucosal oedema may be two uteri with a double vagina.
of the tongue or larynx is best treated with The uterus of most women points forwards
U immediate intramuscular adrenaline and (anteversion) and bends forwards (anteflexion).
antihistamine. Rarely, TRACHEOSTOMY may be However, about 25 per cent of women have a
life-saving. Patients who have had two or more uterus which is pointed backwards (retrover-
episodes can be taught self-injection with a sion) and bent backwards (retroflexion). This is
preloaded adrenaline syringe. a normal variant and very rarely gives rise to any
problems. If it does, the attitude of the uterus
Uterus can be corrected by an operation called a
A hollow, triangular organ, flattened from front ventrosuspension.
to back, the lower angle (or cervix) com-
mincates through a narrow opening (the os Endometritis The lining of the uterine cav-
uteri) with the VAGINA. The uterus or womb is ity is called the ENDOMETRIUM. It is this layer
where the fertilised ovum (egg) normally that is partially shed cyclically in women of
 Uterus, Diseases of 749

reproductive age giving rise to menstruation. most common disorder; in most cases the cause
Infection of the endometrium is called endo- is unknown, although the disorder may be due
metritis and usually occurs after a pregnancy or to excessive production of PROSTAGLANDINS.
in association with the use of an intrauterine
contraceptive device (IUCD see CONTRACEP- Irregular menstruation (variations from
TION). The symptoms are usually of pain, the womans normal menstrual pattern or
bleeding and a fever. Treatment is with anti- changes in the duration of bleeding or the
biotics. Unless the FALLOPIAN TUBES are amount) can be the result of a disturbance in
involved and damaged, subsequent fertility is the balance of OESTROGENS and PROGESTER-
unaffected. Very rarely, the infection is caused ONE hormone which between them regulate the
by TUBERCULOSIS. Tuberculous endometritis cycle. For some time after the MENARCHE or
may destroy the endometrium causing perman- before the MENOPAUSE, menstruation may be
ent amenorrhoea and sterility. irregular. If irregularity occurs in a woman
whose periods are normally regular, it may be
Menstrual disorders are common. Heavy due to unsuspected pregnancy, early miscarriage
periods (menorrhagia) are often caused by or to disorders in the uterus, OVARIES or pelvic
fibroids (see below) or adenomyosis (see below) or cavity. The woman should seek medical advice.
by anovulatory cycles. Anovulatory cycles result
in the endometrium being subjected to Fibroids (leiomyomata) are benign tumours
unopposed oestrogen stimulation and arising from the smooth muscle layer (myo-
occasionally undergoing hyperplasia. Treatment metrium) of the uterus. They are found in 80
is with cyclical progestogens (see PROGESTO- per cent of women but only a small percentage
GEN) initially. If this form of treatment fails, give rise to any problems and may then require
endoscopic surgery to remove the endometrium treatment. They may cause heavy periods and
may be successful. The endometrium may be occasionally pain. Sometimes they present as a
removed using LASER (endometrial laser abla- mass arising from the pelvis with pressure
tion) or electrocautery (transcervical resection symptoms from the bladder or rectum.
of endometrium). Hysterectomy (see below) will Although they can be shrunk medically using
cure the problem if endoscopic surgery fails. gonadorelin analogues, which raise the plasma
Adenomyosis is a condition in which endomet- concentrations of LUTEINISING HORMONE and
rial tissue is found in the muscle layer (myo- FOLLICLE-STIMULATING HORMONE, this is not a
metrium) of the uterus. It usually presents as long-term solution. In any case, fibroids only
heavy and painful periods, and occasionally require treatment if they are large or enlarging,
pain during intercourse. Hysterectomy is usu- or if they cause symptoms. Treatment is either
ally required. myomectomy (surgical removal) if fertility is to
Oligomenorhoea (scanty or infrequent be retained, or a hysterectomy.
periods) may be caused by a variety of condi-
tions including thyroid disease (see THYROID Uterine cancers tend to present after the
GLAND, DISEASES OF). It is most commonly age of 40 with abnormal bleeding (intermen-
associated with usage of the combined oral con- strual or postmenopausal bleeding). They are
traceptive pill. Once serious causes have been usually endometrial carcinomas. Eighty per
eliminated, the patient should be reassured. No cent present with early (Stage I) disease.
treatment is necessary unless conception is Patients with operable cancers should be treated
desired, in which case the patient may require with total abdominal hysterectomy and
induction of ovulation. bilateral excision of the ovaries and Fallopian
Primary amenorrhoea means that the patient tubes. Post-operative RADIOTHERAPY is usually
has never had a period. She should be investi- given to those patients with adverse prognostic
U
gated, although usually it is only due to an factors. Pre-operative radiotherapy is still given
inexplicable delay in the onset of periods by some centres, although this practice is now
(delayed menarche) and not to any serious con- regarded as outdated. PROGESTOGEN treatment
dition. Secondary amenorrhoea is the cessation may be extremely effective in cases of recur-
of periods after menstruation has started. The rence, but its value remains unproven when
most common cause is pregnancy. It may be used as adjuvant treatment. In 2003 in England
also caused by endocrinological or hormonal and Wales, more than 2,353 women died of
problems, tuberculous endometritis, emotional uterine cancer.
problems and severe weight loss. The treatment
of amenorrhoea depends on the cause. Disorders of the cervix The cervix (neck
Dysmenorrhoea, or painful periods, is the of the womb) may produce an excessive
 750 Uterus, Diseases of

discharge due to the presence of a cervical ect- preferable for younger women is the treat-
opy or ectropion. In both instances columnar ment of choice if the cancer is diagnosed early,
epithelium the layer of secreting cells which both resulting in survival rates of five years in
usually lines the cervical canal is exposed on 80 per cent of patients. Wertheims hyster-
its surface. Asymptomatic patients do not ectomy is a major operation in which the
require treatment. If treatment is required, uterus, cervix, upper third of vagina and the
cryocautery local freezing of tissue is usu- tissue surrounding the cervix are removed
ally effective. together with the LYMPH NODES draining the
Cervical smears are taken and examined in area. The ovaries may be retained if desired.
the laboratory to detect abnormal cells shed Patients with cervical cancer are treated by
from the cervix. Its main purpose is to detect radiotherapy, either because they present too
cervical intraepithelial neoplasia (CIN) the late for surgery or because the surgical skill to
presence of malignant cells in the surface tissue perform a radical hysterectomy is not available.
lining the cervix since up to 40 per cent of These operations are best performed by gynae-
women with this condition will develop cervical cological oncologists who are gynaecological
cancer if the CIN is left untreated. Women with surgeons specialising in the treatment of gynae-
abnormal smears should undergo colposcopy, a cological tumours. The role of CHEMOTHERAPY
painless investigation using a low-powered in cervical and uterine cancer is still being
microscope to inspect the cervix. If CIN is evaluated.
found, treatment consists of simply removing
the area of abnormal skin, either using a Prolapse of the uterus is a disorder in
diathermy loop or laser instrument. which the organ drops from its normal situ-
Unfortunately, cervical cancer remains the ation down into the vagina. First-degree pro-
most common of gynaecological cancers. The lapse is a slight displacement of the uterus,
most common type is squamous cell carcinoma second-degree a partial displacement and third-
and around 4,000 new cases (all types) are degree when the uterus can be seen outside the
diagnosed in England and Wales every year. As VULVA. It may be accompanied by a CYSTO-
many as 50 per cent of the women affected may COELE (the bladder bulges into the front wall of
die from the disease within five years. Cervical the vagina), urethrocoele (the urethra bulges
cancer is staged clinically in four bands accord- into the vagina) and rectocoele (the rectal wall
ing to how far it has extended, and treatment is bulges into the rear wall of the vagina). Prolapse
determined by this staging. Stage I involves most commonly occurs in middle-aged women
only the mucosal lining of the cervix and cone who have had children, but the condition is
BIOPSY may be the best treatment in young much less common now than in the past when
women wanting children. In Stage IV the dis- prenatal and obstetric care was poor, women
ease has spread beyond the cervix, uterus had more pregnancies and their general health
and pelvis to the URINARY BLADDER or REC- was poor. Treatment is with pelvic exercises,
TUM. For most women, radiotherapy or radical surgical repair of the vagina or hysterectomy. If
Wertheims hysterectomy the latter being the woman does not want or is not fit for

Vertical section of female reproductive tract (viewed from front) showing sites of common gynaecological
disorders.
 Uvulopalatopharyngoplasty 751

surgery, an internal support called a pessary can Uvea

be fitted and changed periodically. Uvea is a term applied to the middle coat of the
EYE, including the iris, ciliary body and
Hysterectomy Many serious conditions of choroid.
the uterus have traditionally been treated by
hysterectomy, or removal of the uterus. It Uveitis
remains a common surgical operation in the An inflammation of the uveal tract (see EYE).
UK, but is being superseded in the treatment of Iritis is inflammation of the iris; cyclitis,
some conditions, such as persistent MENOR- inflammation of the ciliary body; and choroidi-
RHAGIA, with endometrial ablation removal tis, inflammation of the choroid. The symp-
of the lining of the uterus using minimally inva- toms and signs vary according to which part of
sive techniques, usually using an ENDOSCOPE the uveal tract is involved and tend to be recur-
and laser. Hysterectomy is done to treat rent. The patient may experience varying
fibroids, cancer of the uterus and cervix, men- degrees of discomfort or pain, with or without
orrhagia, ENDOMETRIOSIS and sometimes for blurring of vision. In many cases a cause is
severely prolapsed uterus. Total hysterectomy is never found. Some known associations include
the usual type of operation: it involves the various types of arthritis, some bowel diseases,
removal of the uterus and cervix and sometimes virus illnesses, tuberculosis, syphilis, parasites
the ovaries. After hysterectomy a woman no and fungi. Treatment is with anti-inflammatory
longer menstruates and cannot become preg- drops and occasionally steroid tablets, plus
nant. If the ovaries have been removed as well drops to dilate the pupil.
and the woman had not reached the meno-
pause, hormone replacement therapy (HRT Uvula
see MENOPAUSE) should be considered. Counsel- The small mass of muscle covered by mucous
ling helps the woman to recover from the oper- membrane that hangs down from the middle of
ation which can be an emotionally challenging the soft PALATE on its posterior aspect. Its func-
event for many. tion is not certain and it seldom causes
problems.
Utricle
(1) Part of the membraneous labyrinth within Uvulopalatopharyngoplasty
the vestibule of the EAR. Surgery to excise the UVULA, part of the soft
(2) Prostatic utricle is a small sac extending out PALATE and the TONSILS. It is done to help
of the male URETHRA into the matrix of the people with severe SNORING problems but it
PROSTATE GLAND. does not always achieve a cure.

U
 degree of immunity for six months. (See

V CHOLERA.)

Diphtheria vaccine is available in several

forms. It is usually given along with tetanus and
pertussis vaccine (see below) in what is known as
TRIPLE VACCINE. This is given in three doses:
Vaccination the first at the age of two months; the second at
Named from vacca, Latin for cow, vaccination three months; and the third at four months,
means inoculation with the material of cow- with a booster dose at the age of five years. (See
pox, performed to afford protection to the DIPHTHERIA.)
inoculated person against an attack of SMALL-
POX, or to reduce seriousness of, and averting
Hay fever vaccine is a vaccine prepared
a fatal result from, any such attack. The term from the pollen of various grasses. It is used in
is often used, inaccurately, to refer to gradually increasing doses for prevention of HAY
IMMUNISATION.
FEVER in those susceptible to this condition.

Vaccine
The name applied generally to dead or attenu- Influenza vaccine A vaccine is now avail-
ated living infectious material introduced into able for protection against INFLUENZA due to
the body, with the object of increasing its power the influenza viruses A and B. Its use in Britain
to resist or to get rid of a disease. (See also is customarily based on advice from the health
IMMUNITY.)
departments according to the type of influenza
Healthy people are inoculated with vaccine expected in a particular year.
as a protection against a particular disease; this
produces ANTIBODIES which will confer Measles, mumps and rubella (MMR)
immunity against a subsequent attack of the vaccines are given in combination early in
disease. (See IMMUNISATION for programme of the second year of life. A booster dose may
immunisation during childhood.) prove necessary, as there is some interference
Vaccines may be divided into two classes: between this vaccine and the most recent form
stock vaccines, prepared from micro-organisms of pertussis vaccine (see below) offered to chil-
known to cause a particular disease and kept in dren. Uptake has declined a little because of
readiness for use against that disease; and media reports suggesting a link with AUTISM
autogenous vaccines, prepared from micro- for which no reliable medical evidence (and
organisms which are already in the patients much to the contrary) has been found by
body and to which the disease is due. Vaccines investigating epidemiologists. (See also separate
intended to protect against the onset of disease entry for each disease, and for MMR VACCINE.)
are of the former variety.
Pertussis (whooping-cough) vac-
Autogenous vaccines are prepared by cine is prepared from Bordetella pertussis, and
cultivating bacteria found in SPUTUM, URINE is usually given along with diphtheria and tet-
and FAECES, and in areas of inflammation such anus in what is known as triple vaccine. (See also
as BOILS (FURUNCULOSIS). This type of vaccine WHOOPING-COUGH.)
was introduced by Wright about 1903.
Plague vaccine was introduced by Haffk-
Anthrax vaccine was introduced in 1882 ine, and appears to give useful protection, but
for the protection of sheep and cattle against the duration of protection is relatively short:
this disease. A safe and effective vaccine for use from two to 20 months. Two injections are
in human beings has now been evolved. (See given at an interval of four weeks. A reinforcing
ANTHRAX.) dose should be given annually to anyone
exposed to PLAGUE.
BCG vaccine is used to provide protection
against TUBERCULOSIS. (See also separate entry Poliomyelitis vaccine gives a high degree
on BCG VACCINE.) of protection against the disease. This is given
in the form of attenuated Sabin vaccine which
Cholera vaccine was introduced in India is taken by mouth a few drops on a lump of
about 1894. Two injections are given at an sugar. Reinforcing doses of polio vaccine are
interval of at least a week; this gives a varying recommended on school entry, on leaving
 Vacuole 753

school, and on travel abroad to countries where chick embryos injected with the living, attenu-
POLIOMYELITIS is ENDEMIC. ated strain (17D) of pantropic virus. Only one
injection is required, and immunity persists
Rabies vaccine was introduced by Pasteur for many years. Re-inoculation, however, is
in 1885 for administration, during the long desirable every ten years. (See YELLOW FEVER.)
incubation period, to people bitten by a mad
dog, in order to prevent the disease from devel- Haemophilus vaccine (HiB) This vaccine
oping. (See RABIES.) was introduced in the UK in 1994 to deal with
the annual incidence of about 1,500 cases and
Rubella vaccine, usually given with 100 deaths from haemophilus MENINGITIS,
mumps and measles vaccine in one dose SEPTICAEMIA and EPIGLOTTITIS, mostly in
called MMR VACCINE, see also above now pro- pre-school children. It has been remarkably
vides protection against RUBELLA (German successful when given as part of the primary
measles). It also provides immunity for ado- vaccination programme at two, three and four
lescent girls who have not had the disease in months of age reducing the incidence by over
childhood and so ensures that they will not 95 per cent. A few cases still occur, either due to
acquire the disease during any subsequent other subgroups of the organism for which the
pregnancy thus reducing the number of con- vaccine is not designed, or because of
genitally abnormal children whose abnormality inadequate response by the child, possibly related
is the result of their being infected with rubella to interference from the newer forms of pertus-
via their mothers before they were born. sis vaccine (see above) given at the same time.

Smallpox vaccine was the first introduced. Meningococcal C vaccine Used in the
As a result of the World Health Organisations UK from 1998, this has dramatically reduced
successful smallpox eradication campaign it the incidence of meningitis and septicaemia
declared the disease eradicated in 1980 there due to this organism. Used as part of the pri-
is now no medical justification for smallpox mary programme in early infancy, it does not
vaccination. Recently, however, there has been protect against other types of meningococci.
increased interest in the subject because of the
potential threat from bioterrorism. (See also Varicella vaccine This vaccine, used to
VACCINATION.) protect against varicella (CHICKENPOX) is used
in a number of countries including the United
Tetanus vaccine is given in two forms: (1) States and Japan. It has not been introduced
In the so-called triple vaccine, combined with into the UK, largely because of concerns that
diphtheria and pertussis (whooping-cough) use in infancy would result in an upsurge in
vaccine for the routine immunisation of chil- cases in adult life, when the disease may be
dren (see above). (2) By itself to adults who have more severe.
not been immunised in childhood and who are
particularly exposed to the risk of TETANUS, Pneumococcal vaccine The pneumococ-
such as soldiers and agricultural workers. cus is responsible for severe and sometimes fatal
childhood diseases including meningitis and
Typhoid vaccine was introduced by Wright septicaemia, as well as PNEUMONIA and other
and Semple for the protection of troops in the respiratory infections. Vaccines are available but
South African War and in India. TAB vaccine, do not protect against all strains and are
containing Salmonella typhi (the causative reserved for special situations such as for
organism of typhoid fever see ENTERIC FEVER) patients without a SPLEEN or those who are
and Salmonella paratyphi A and B (the organ- immunodeficient.
isms of paratyphoid fever see ENTERIC FEVER)
has now been replaced by typhoid monovalent Vaccinia V
vaccine, containing only S. typhi. The change Vaccinia is another term for cowpox, a disease
has been made because the monovalent vaccine in which vesicles form on the udders and teats
is less likely to produce painful arms and gen- of cows, due to the same virus as is responsible
eral malaise, and there is no evidence that the for SMALLPOX in humans. It is also the term
TAB vaccine gave any protection against para- used to describe the reaction to smallpox
typhoid fever. Two doses are given at an interval VACCINATION.
of 46 weeks, and give protection for 13 years.
Vacuole
Yellow fever vaccine is prepared from A space inside the cytoplasm of CELLS. It is
 754 Vacuum Extractor

formed by a folding-in of the cellular mem- child. It may also be due to some local, painful
brane when the cell ingests material from the condition such as inflammation.
outside for example, when white blood cells
attack BACTERIA. Vaginitis
Inflammation of the VAGINA. (See
Vacuum Extractor LEUCORRHOEA.)
Also called a ventouse. The idea of the glass
suction cup applied to the emerging head of the Vagotomy
baby to assist in delivery was first considered by The operation of cutting the fibres of the VAGUS
Younge in 1706, but it was not until 1954 that nerve to the stomach. It was once part of the
the modern (ventouse) vacuum extractor was routine surgical treatment of DUODENAL
introduced. The value of the ventouse as against ULCER, the aim being to reduce the flow or acid-
the FORCEPS has been disputed in different ity of the gastric juice. The operation is now
clinics, the former being less popular in the UK. performed on those patients who fail to
Indications are similar for the use of obstetric respond to drug treatment. (See also STOMACH,
forceps. Even if the OCCIPUT is not in the DISEASES OF Gastric ulcer).
anterior position, the extractor may still be
applied; many obstetricians would choose for- Vagus
ceps or perform manual rotation of the fetus in The tenth cranial nerve. Unlike the other cra-
such cases. nial nerves, which are concerned with the spe-
In cases of prolongation of the first stage of cial senses, or distributed to the skin and
labour, the ventouse may be used to accelerate muscles of the head and neck, this nerve (as its
dilatation of the cervix provided that the name implies Latin for wanderer), passes
cervix is already sufficiently dilated to allow downwards into the chest and abdomen, sup-
application of the cup. The ventouse cannot plying branches to the throat, lungs, heart,
be applied to the breech or face; in urgent stomach and other abdominal organs. It con-
cases of fetal distress the operation takes too tains motor, secretory, sensory and vasodilator
long, and forceps delivery is preferred. There fibres.
is some doubt about its safety when used on
premature babies; many obstetricians feel that Valgus
forceps delivery reduces the risk of intracranial This term means literally knock-kneed, and is a
haemorrhage. The vacuum extractor, while bending inward at the knees (genu valgum), or
resulting in a slower delivery than when for- at the ankle, as occurs in FLAT-FOOT (pes
ceps are used, has a lower risk of damage to planus).
the mothers birth canal. (See PREGNANCY
AND LABOUR Some complications of Validity
labour.) An indication of how much a clinical test or
sign is an accurate indicator of the presence of
Vagina disease. Reduced validity may occur because (1)
The lower part of the female reproductive tract identical tests repeated on the same person in
(see REPRODUCTIVE SYSTEM) through which a similar circumstances produce variable results;
baby is delivered. It is a muscular passage lead- (2) the same observer gets different results on
ing from the labial entrance to the UTERUS. It is successive occasions intraobserver error; (3)
lined with mucous membrane and receives the different observers produce different results.
erect PENIS during sexual intercourse. The
semen is ejaculated into the upper part of Valine
the vagina; from there the sperms must pass One of the essential (indispensable) AMINO
through the cervix and uterus to fertilise the ACIDS.
V ovum in the Fallopian tube.
Valium
Vaginismus The proprietary name for diazepam, a widely
Spasmodic painful, involuntary contraction of used anxiolytic drug (see ANXIOLYTICS).
the opening of the VAGINA on attempted coitus
(sexual intercourse). It is usually psychological Valsalvas Manoeuvre
in origin due, for instance, to fear that pene- This is carried out by closing the mouth, hold-
tration by the penis will be painful, or because ing the nose and attempting to blow hard. The
of some previous traumatic incident of sexual manoeuvre raises pressure in the chest and,
intercourse such as rape or sexual abuse as a indirectly, the abdomen and forces air from
 Vas 755

the back of the nose down the EUSTACHIAN including the STAPHYLOCOCCUS. The drug has
TUBES to the middle ear. This latter effect can a limited use by the intravenous route in the
be used to clear the tube during descent in an prophylaxis and treatment of ENDOCARDITIS
aircraft, when it sometimes becomes blocked or and other serious infections caused by gram-
partially blocked, producing differential pres- positive cocci in particular, METHICILLIN-
sures on the two sides of each eardrum, usually RESISTANT STAPHYLOCOCCUS AUREUS (MRSA).
accompanied by temporary pain and deafness. It need be given only every 12 hours, although
Valsalvas manoeuvre is involuntarily per- plasma concentrations should be monitored
formed when a person strains to open his or her (especially in patients with renal impairment,
bowels: in these circumstances the passage of air when the dose may need marked reduction). It
to the lungs is blocked by instinctive closure of can both damage the middle ear and the kidney.
the vocal cords in the LARYNX. The resultant A short course of vancomycin is effective in the
raised abdominal pressure helps to expel the treatment of antibiotic-associated COLITIS, for
bowel contents. The manoeuvre is also used in which it is given by mouth.
the study of cardiovascular physiology because
the rise in pressure in the chest restricts the Van Den Bergh Test
return of venous blood to the right atrium of A test done on SERUM from patients with
the HEART. Pressure in the peripheral VEINS is JAUNDICE to discover whether the excess BILI-
raised and the amount of blood entering and RUBIN in the blood which causes the jaundice
leaving the heart falls. This drop in cardiac out- is conjugated or unconjugated. If conjugated,
put may cause the subject to faint because the this indicates that HAEMOLYSIS is causing the
supply of oxygenated blood to the brain is jaundice; if unconjugated, disease of the LIVER
reduced. or BILE DUCT is the likely diagnosis.

Valves Vaporiser
These cup-like structures are found in the A device that via a narrow nozzle turns water or
HEART, VEINS, and lymphatic vessels (see a drug into a fine spray, thus enabling medicine
LYMPH); they ensure that the circulation of to be taken by INHALATION. It is used, for
the blood and lymph goes always in one example, in the treatment of ASTHMA.
direction.
Variance
Valvotomy See STANDARD DEVIATION.
An operation that opens a stenosed heart valve
(see STENOSIS; HEART, DISEASES OF) and allows it Varicella
to function properly again. Various techniques Another name for CHICKENPOX.
are used, including a dilating instrument, a bal-
loon or open-heart surgery. Varicocele
A condition in which the veins of the TESTICLE
Valvular Disease are distended. (See TESTICLE, DISEASES OF.)
See under HEART, DISEASES OF.
Varicose Veins
Valvuloplasty VEINS that have become stretched and dilated.
An operation to repair or reconstruct a defective (See VEINS, DISEASES OF.)
heart valve (see VALVES). It may be done as an
open-heart procedure (with the patient tem- Variola
porarily connected to a HEART-LUNG MACHINE Another name for SMALLPOX.
that maintains the circulation of oxygenated
blood); alternatively, valvuloplasty can now be Varix
performed using a specially designed balloon- An enlarged and tortuous vein (see VEINS). V
ended catheter (see CATHETERS) passed through
the skin into a blood vessel and on to the heart. Varus
The balloon is inflated and the flaps of a A term meaning inward displacement of a part
narrowed (stenosed) valve are prised apart. of the body for example, the knee (genu
varum) or the ankle (talipes varus).
Vancomycin
An antibiotic derived from streptomyces, which Vas
is active against a wide range of gram-positive The Latin term for a vessel or duct, especially a
organisms (see BACTERIA; GRAMS STAIN), blood vessel.
 756 Vasa Efferentia

Vasa Efferentia Vasoconstrictors

Efferent seminal ducts of the testis (see TES- Vasoconstrictor sympathomimetic drugs, such
TICLE); these carry SEMEN from the testis to the as EPHEDRINE and NORADRENALINE, raise the
head of the EPIDIDYMIS. BLOOD PRESSURE temporarily by acting on
receptors that constrict peripheral blood vessels.
Vascular They are occasionally used as a quick way of
Relating to the blood vessels. raising blood pressure when other measures
have failed, but they have potentially serious
Vasculitis side-effects on the kidney. Vasoconstrictors are
Inflammation of the blood vessels. This may also used with local anaesthetics (see under
damage the lining of the vessels and cause nar- ANAESTHESIA) to counteract the latters vaso-
rowing or blockage, thus restricting blood flow. dilator effect. Adrenaline will reduce local
This, in turn, may harm or destroy the tissues blood flow, slow the absorption of anaesthetic
supplied by the affected blood vessels. Vasculitis and prolong its effect.
is probably caused by small particles called
immune complexes, circulating in the blood, Vasodilators
that adhere to the vessel walls and provoke Substances that dilate blood vessels. Coronary
inflammation. Normally these complexes are vasodilators, such as NITRATES, CALCIUM-
consumed by the white blood cells. Vasculitis is CHANNEL BLOCKERS and POTASSIUM-CHANNEL
the basic disease process in several disorders ACTIVATORS, are used in heart failure to
such as POLYARTERITIS NODOSA, ERYTHEMA improve blood supply to the heart. Peripheral
nodosum, TEMPORAL ARTERITIS and SERUM vasodilators affect the blood vessels in the limbs
SICKNESS. and are used to treat conditions due to poor
circulation such as CHILBLAIN and RAYNAUDS
Vas Deferens DISEASE.
A narrow tube that leads from each testis (see
TESTICLE) through the PROSTATE GLAND to join Vasomotor Centre
a tube from the seminal vesicles to form the The description vasomotor refers to control of
ejaculatory duct. Sperm (see SPERMATOZOON) the muscular walls of blood vessels, particularly
and seminal fluid pass through this duct during ARTERIES, dilating or constricting their diam-
ejaculation. eters. The vasomotor centre is a group of
neurons (see NEURON(E)) in the MEDULLA
Vasectomy OBLONGATA of the BRAIN; they receive messages
The surgical operation performed to render from sensory receptors in the circulatory sys-
men sterile, or infertile. It consists of ligating, or tem, and engineer reflex alterations in the heart
tying, and then cutting the ductus, or vas, rate and blood-vessel diameters in order to
deferens (see TESTICLE). It is quite a simple adjust the blood pressure. The centre also
operation carried out under local anaesthesia, receives transmission from other parts of the
through a small incision or cut (or sometimes brain enabling emotions fear or anger to
two) in the upper part of the SCROTUM. It has influence blood pressure. The vasomotor centre
no effect on sexual drive or ejaculation, and operates through the vasomotor nerves of the
does not cause impotency. It is not immediately SYMPATHETIC NERVOUS SYSTEM and the PARA-
effective, and several tests, spread over several SYMPATHETIC NERVOUS SYSTEM.
months, must be carried out before it is safe to
assume that sterility has been achieved. Fertility Vasomotor Nerves
can sometimes be restored by a further oper- Small nerve fibres that lie upon the walls of
ation, to restore the continuity of the vas; this blood vessels and connect the muscle fibres of
cannot be guaranteed, and only seems to occur their middle coat with the NERVOUS SYSTEM.
V in about 20 per cent of those who have had the Through these nerves the blood vessels are
operation. retained in a state of moderate contraction.
There are vasodilator nerves, through which are
Vasoconstriction transmitted impulses that dilate the vessels,
Narrowing of blood vessels which results in the and, in the case of the skin vessels, produce the
blood flow to a particular part of the body condition of blushing; there are also vaso-
being reduced. Cold will cause vasoconstriction constrictor nerves which transmit impulses that
of the vessels under the skin, thus reducing heat constrict, or narrow, the blood vessels as
loss. SHOCK due to injury or loss of blood will occurs on exposure to cold (see HYPOTHERMIA).
also provoke vasoconstriction. Various drugs produce dilatation or contraction
 Veins 757

of the blood vessels, and several of the sub- meat and fish from their diets, include foods of
stances produced by ENDOCRINE GLANDS in the animal origin, such as milk, cheese, eggs, and
body have these effects: for example, butter. Such a diet should supply an adequate
ADRENALINE. balance of nutrients, although people with spe-
cial dietary requirements such as pregnant or
Vasopressin feeding mothers, and very strict vegetarians
The fraction isolated from extract of the pos- may require dietary supplements (see APPENDIX
terior PITUITARY GLAND lobe which stimulates 5: VITAMINS).
intestinal activity, constricts blood vessels, and
inhibits the secretion of URINE. It is also known Vegetations
as the antidiuretic hormone (ADH) because of Roughenings, comprising FIBRIN and blood
this last effect, and its only use in medicine is in cells, that appear upon the valves of the heart,
the treatment of DIABETES INSIPIDUS. usually as the result of acute RHEUMATISM.
They lead in time to narrowing of the openings
Vasovagal Attack from the cavities of the heart, or to imcompe-
The temporary loss of consciousness caused by tence of the valves that close these openings. (See
an abrupt slowing of the heartbeat. This may HEART, DISEASES OF.)
happen following SHOCK, acute pain, fear, or
stress. A common cause of fainting in normal Vehicle
people, a vasovagal attack may be a con- A pharmaceutical term to describe the medium
sequence of overstimulation of the VAGUS nerve in which a drug is administered for example, a
which is involved in the control of breathing fluid, gel, powder or aerosol.
and the circulation.
Veins
VD The vessels which return the blood to the heart
The abbreviation for venereal disease (see SEXU- after it has circulated through the tissues; they
ALLY TRANSMITTED DISEASES (STDS)). The word are both more numerous and more capacious
venereal is derived from Venus, the Roman than the ARTERIES.
goddess of love.
Structure While of similar structure to an
Vector artery, veins have much thinner walls, with
An animal that is the carrier of a particular much less muscular tissue. Furthermore, most
infectious disease (see INFECTION). A vector veins have one-way VALVES to ensure that the
picks up the infectious agent (bacterium see blood flows in the right direction. These are
BACTERIA; also RICKETTSIA; VIRUS) from an most numerous in the legs, then the arms, with
infected persons blood or faeces and carries it few in the internal organs.
in or on its body before depositing the agent on
or into a new host. Fleas, lice, mosquitoes and Chief veins Four pulmonary veins open
ticks are among common vectors of disease to into the left atrium of the heart, two from each
humans. When a vector is used by the infec- lung. The superior vena cava returns the blood
tious agent to complete part of its life-cycle from the head, neck, and arms; while the
for example, the malarial agent PLASMODIUM inferior vena cava returns blood from the legs
conducts part of its life-cycle in the mosquito and abdomen. The large basilic vein that runs
the vector is described as biological. If the vec- up the inner side of the upper arm is the vein
tor simply carries the agent but is not a host for usually opened in blood-letting (see VENESEC-
part of its life-cycle, the vector is described as TION). The great saphenous vein is of special
mechanical. Flies, for example, may carry an interest, because of its liability to become dis-
infection such as bacterial dysentery from tended or varicose. Within the abdomen, the
infected faeces to the fingers of another host. inferior vena cava receives branches correspond- V
ing to several branches of the aorta, its largest
Veganism branches being the hepatic veins, which return
A strict form of VEGETARIANISM. Vegans do not not only the blood that has reached the liver in
eat meat, dairy produce, eggs or fish. the hepatic arteries, but also blood which
comes from the digestive organs in the PORTAL
Vegetarianism VEIN to undergo a second capillary circulation
Restriction of ones diet, for health, cultural or in the liver.
humanitarian reasons, to foods of fruit or vege- There are several connections between the
table origin. Most vegetarians, while excluding superior and inferior cava, the most important
 758 Veins, Diseases of

being three azygos veins that lie upon the sides cosmetic purposes. Treatment alternatives
of the spinal column, the veins on the front of include injection with sclerosing agents to
the abdomen, and some veins that emerge from obliterate the lumen of the veins (sclero-
the abdomen at the navel and connect the por- therapy), or surgery; in the elderly or unfit, an
tal system with those of the inferior and elastic stocking may suffice. One operation is
superior vena cava. (See also CIRCULATORY SYS- the Trendelenburg operation in which the
TEM OF THE BLOOD.) saphenous vein is disconnected from the fem-
oral vein and individual varicose veins are
Veins, Diseases of avulsed. (See also VASCULITIS.)
Veins are the blood vessels that convey blood
back from the tissues towards the heart. Two Thrombosis Thrombosis occurs when
common conditions that affect them are blood, which is normally a liquid, clots within
THROMBOSIS and varicosities (see below). the vein to form a semisolid thrombus (clot).
This occurs through a combination of reduced
Varicose veins are dilated tortuous veins blood flow and hypercoagulability (a reduced
occurring in about 15 per cent of adults threshold for clotting). The most common site
women more than men. They most commonly for this to occur is in the deep veins of the leg,
occur in the legs but may also occur in the anal where it is known as a deep-vein thrombosis
canal (HAEMORRHOIDS) and in the oesophagus (DVT).
(due to liver disease). Predisposing factors include immobility
Normally blood flows from the subcutaneous (leading to reduced blood flow), such as during
tissues to the superficial veins which drain via long journeys (e.g. plane flights) where there is
perforating veins into the deep veins of the leg. little opportunity to stretch ones legs; surgery
This flow, back towards the heart, is aided by (leading to temporary post-operative immobil-
valves within the veins. When these valves fail, ity and hypercoagulability of blood); oestrogen
increased pressure is exerted on the blood ves- administration (low-dose oestrogen oral contra-
sels leading to dilatations known as varicose ceptives carry a very low relative risk); and sev-
veins. eral medical illnesses such as heart failure,
Treatment is needed to prevent complica- stroke and malignancy.
tions such as ulceration and bleeding, or for Deep-vein thrombosis presents as a tender,
warm, red swelling of the calf. Diagnosis may
be confirmed by venogram (an X-ray taken fol-
lowing injection of contrast medium into the
foot veins) or by ultrasound scanning looking
for flow within the veins.
Prevention is important. This is why patients
are mobilised and/or given leg exercises very
soon after an operation, even major surgery.
People should avoid sitting for long periods,
particularly if the edge of the seat is hard, thus
impeding venous return from the legs. Car
drivers should stop regularly on a long journey
and walk around; airline travellers should,
where possible, walk round the aisle(s) and also
exercise and massage their leg muscles, as well as
drinking ample non-alcoholic fluids.
Diagnosis and treatment are important
because there is a risk that the clotted blood
V within the vein becomes dislodged and travels
up the venous system to become lodged in the
pulmonary arteries. This is known as PULMON-
ARY EMBOLISM.
Treatment is directed at thinning the blood
with ANTICOAGULANTS, initially with heparin
(Top) Normal vein showing how a closed valve pre- and subsequently with WARFARIN for a period
vents back flow of blood. (Bottom) Vein with faulty of time while the clot resolves.
valve which allows some blood to leak back Blocked superficial veins are described as
through the part-opened valve. superficial thrombophlebitis, which produces
 Ventricle 759

inflammation over the vein. It responds to anti- public places. Special filters may be used to
inflammatory analgesics. Occasionally heparin reduce the risk of airborne infections and aller-
and ANTIBIOTICS are required to treat associated gies (see ALLERGY), but poorly maintained and
thrombosis and infection. contaminated systems may result in outbreaks
of serious disorders, such as LEGIONNAIRES
Vena Cava DISEASE. Sterilisation of air is rarely required,
The name of either of the two large vessels that but ultraviolet light is sometimes used to kill
open into the right atrium of the HEART. (See pathogenic organisms. (See also ASTHMA; BRON-
VEINS.) CHITIS; HUMIDIFICATION.)

Venepuncture Ventilation, Artificial

The insertion of a needle into a vein (see VEINS), The procedure, usually carried out in an oper-
usually for the purpose of injecting a drug or ating theatre or intensive-care unit, in which a
withdrawing blood for haematological or bio- device called a VENTILATOR takes over a per-
chemical analysis. The usual site for vene- sons breathing. This is done for someone who
puncture in adults is the median cubital vein in is unable to breathe normally. Damage to the
the forearm. respiratory centre of the brain as a result of
head injury, disease of the brain, or an over-
Venereal Diseases dose of sedative or narcotic drugs may affect
See SEXUALLY TRANSMITTED DISEASES (STDS). the respiratory centre. Chest injuries, disease
of the lungs, nerve or muscle disorders or sur-
Venesection gery of the chest or abdomen can also affect
Venesection, or blood-letting, may be employed breathing and require the use of a ventilator to
for two purposes. Most commonly, small quan- maintain normal breathing. Artificial ventila-
tities of blood may be required for analysis, as tion can also be carried out as an emergency
an aid to diagnosis or control of various dis- by mouth-to-mouth resuscitation. (See also
eases. For example, knowledge of the plasma ANAESTHESIA; ARTIFICIAL VENTILATION OF
glucose concentration is important in the diag- THE LUNGS.)
nosis and management of DIABETES MELLITUS,
or blood may be required in order to test for Ventilator
infections such as HIV or HEPATITIS. Blood may Machinery used to provide artificial ventilation.
be obtained by pricking a fingertip, or inserting Also called a respirator or life-support machine,
a needle into a vein, depending on the amount it is an electric pump linked to a supply of air
required. Controlled bleeding of larger which it pumps into the patient through an
amounts may rarely be used in certain cases of endotracheal tube passed through the nose or
acute heart failure, as a rapid and temporary mouth into the trachea (see ENDOTRACHEAL
method of relieving the strain on the heart. It is INTUBATION). Sometimes the air is pumped
also used in the treatment of POLYCYTHAEMIA. straight into the trachea through an artificial
hole called a TRACHEOSTOMY. During ventila-
Venography tion the patients blood gases are closely moni-
The study of the VEINS, particularly by means tored and other bodily activities such as pulse
of X-rays after the veins have been injected with and heart pressure are regularly measured. Some
a radio-opaque substance. patients need to be kept on a ventilator for sev-
eral days or even weeks if their medical condi-
Venous Ulcer tion is serious. (See also ARTIFICIAL VENTILATION
See under ULCER. OF THE LUNGS.)

Ventilation Ventouse
(1) Passage of air into and out of the RESPIRA- See VACUUM EXTRACTOR. V
TORY SYSTEM.
(2) The process by which air is purified and Ventral
circulated in domestic, occupational, industrial, Positioned or relating to the front of a body or
and other settings. Ideally, the air we breathe to the front part of an organ.
should be of the right temperature and humid-
ity, and free of dust, smoke, pollen, and other Ventricle
contaminants. Ventilation aims to produce (1) The term applied to the two lower cavities
such an atmosphere. Air-conditioning is fre- of the HEART, and also to the four main cavities
quently used in hospitals, offices, and other within the BRAIN.
 760 Ventricular Fibrillation

Ventricular Fibrillation kill, or expel, parasitic worms from the

A potentially life-threatening and rapid intestines.
ARRHYTHMIA of the ventricle of the HEART.
Vernix
Ventricular Hypertrophy The white, cheese-like substance that covers the
Enlargement of the ventricular chambers of the skin of a newborn infant. It consists of dead
HEART, a common complication of HYPERTEN- cells in a fatty secretion, protects the infants
SION and coronary artery disease (see HEART, skin, and helps lubricate its passage through the
DISEASES OF). Treatment is of the underlying cervix and vagina during delivery.
conditions and cardiac drugs which facilitate
the working of the heart. Verruca
See WARTS.
Ventricular Septal Defect
An inherited defect of the HEART. The septum Verrucose
(partition) separating the two ventricles is This term means having a surface resembling
pierced by a hole which, if large, results in verrucae (see WARTS). Certain skin diseases may
blood being diverted to the LUNGS at a greater become verrucose.
pressure than normal. This may lead to irrevers-
ible PULMONARY HYPERTENSION, which early Version
surgical intervention (repair of the septal defect) The name given to an operation in OBSTETRICS
should prevent. A quarter of patients with VSD which consists in turning the FETUS in the
have other cardiac defects. Half of the defects UTERUS where the fetus is lying in an abnormal
seal themselves spontaneously. position which may make eventual delivery
difficult. In particular, version (which can take
Ventriculography place spontaneously) may be done on a fetus
The process of taking an X-ray photograph of between the 34th and 37th weeks of pregnancy
the BRAIN after the fluid in the lateral ventricles when its buttocks rather than its head are posi-
of the brain has been replaced by air; in this way tioned at the cervical end of the uterus. The
any alteration in the outline of the ventricles procedure carries a small risk of precipitating
(e.g. from pressure by a tumour) can be premature labour, and it is not always success-
detected. ful, in which case a breech delivery is
attempted or, in difficult cases, a CAESAREAN
Ventrosuspension SECTION is performed. (See also PREGNANCY
This is a surgical procedure to fixate a displaced AND LABOUR.)
UTERUS to the front wall of the abdomen. It is
usually done by shortening the supporting Vertebra
round ligaments either where they are attached One of the irregularly shaped bones that
to the uterus, or to the abdominal wall. together form the vertebral column. (See SPINAL
COLUMN.)
Venule
A very small blood vessel that drains blood from Vertebrobasilar Insuffiency
CAPILLARIES. Several venules join up to form a Intermittent incidents of double vision, dizzi-
vein (see VEINS). ness, weakness and speaking difficulties caused
by a reduced blood supply to parts of the BRAIN.
Verapamil The cause is usually obstruction in the basilar,
Verapamil is a drug used in the treatment of vertebral and other arteries at the base of
HYPERTENSION, disordered rhythms of the the brain. The condition is sometimes the
heart, and ANGINA PECTORIS. The drug is one precursor of a STROKE.
V of the CALCIUM-CHANNEL BLOCKERS and acts
by reducing cardiac output and slowing the Vertigo
heart rate. It may, however, precipitate heart A condition in which the affected person loses
failure, cause HYPOTENSION and aggravate con- the power of balancing him or herself, and has a
duction problems in the heart, so should be false sensation as to his or her own movements
prescribed with care. It should not be used with or those of surrounding objects. The power of
BETA-ADRENOCEPTOR-BLOCKING DRUGS. balancing depends upon sensations derived
partly through the sense of touch, partly from
Vermicides the eyes, but mainly from the semicircular
Also called vermifuges, these are substances that canals of the internal EAR the vestibular
 Vestibule 761

mechanism. In general, vertigo is due to some HISTAMINE DRUGS and PHENOTHIAZINES for
interference with this vestibular ocular reflex example, prochlorperazine are often effective
mechanism or with the centres in the cerebel- in preventing and treating these disorders. Cin-
lum and cerebrum (see BRAIN) with which it is narizine and betahistine have been marketed as
connected. Giddiness is often associated with effective drugs for Menires disease; for acute
headache, nausea and vomiting. attacks, cyclizine or prochlorperazine given by
intramuscular injection or rectally can be of
Causes The simplest cause of vertigo is some value. Research in America is exploring the use
mechanical disturbance of the body affecting of virtual-reality technology to change subjects
the fluid in the internal ear; such as that pro- visual perception of the outside world gradually
duced by moving in a swing with the eyes shut, during several 30-minute sessions, helping
the motion of a boat causing sea-sickness, or them to adjust to the abnormal sensations
a sudden fall. (See also MOTION (TRAVEL) that occur during an attack. Early results are
SICKNESS.) promising.
Another common positional variety is
benign paroxysmal positional vertigo (BPPV) Vesical
caused by sudden change in the position of the The term applied to structures connected with,
head; this causes small granular masses in the or diseases of, the URINARY BLADDER.
cupola of the posterior semicircular canal in
the inner ear to be displaced. It may subside Vesicants
spontaneously within a few weeks but can recur. Vesicants are blistering agents.
Sometimes altering the position of the head so
as to facilitate return of the crystals to the Vesicle
cupola will stop the vertigo. A PAPULE containing fluid, for example as seen
The cause which produces a severe and sud- in CHICKENPOX.
den giddiness is MENIRES DISEASE, a con-
dition in which there is loss of function of the Vesico-Ureteric Reflux
vestibular mechanism of the inner ear. An acute The back flow of URINE from the URINARY
labyrinthitis inflammation of the labyrinth of BLADDER into the ureters (see URETER). The
the ear may result from viral infection and cause is defects in the VALVES which normally
produce a severe vertigo lasting 25 days. prevent this reflux from occurring. If, in
Because it often occurs in epidemics it is often addition, the patient usually a child acquires
called epidemic vertigo. Vertigo is sometimes bacteria in the bladder, the consequence may be
produced by the removal of wax from the ear, or one or more attacks of PYELONEPHRITIS caused
even by syringing out the ear. (See EAR, DISEASES by the infected urine gaining access to the kid-
OF.) ney pelvis. Diagnosis is by imaging techniques.
A severe upset in the gastrointestinal tract Treatment is by long-term antibiotics while
may cause vertigo. Refractive errors in the eyes, awaiting spontaneous recovery. Occassionally,
an attack of MIGRAINE, a mild attack of EPI- corrective surgery is required.
LEPSY, and gross diseases of the brain, such as
tumours, are other causes acting more directly Vesicovaginal Fistula
upon the central nervous system. Finally, giddi- A false communication between the URINARY
ness may be due to some disorder of the circula- BLADDER and the VAGINA. The result is urinary
tion, for example, reduced blood supply to the INCONTINENCE. Surgical damage to the blad-
brain produced by fainting, or by disease of the der during operations for gynaecological dis-
heart. orders is one possible cause. Another is tissue
damage following radiotherapy for cancer in
Treatment While the attack lasts, this the pelvis.
requires the sufferer to lie down in a dark- V
ened, quiet room. SEDATIVES have most influ- Vesicular Breathing
ence in diminishing giddiness when it is dis- Normal breath sounds heard in the lung by
tressing. After the attack is over, the indi- means of a stethoscope. These are soft regular
vidual should be examined to establish the sounds which become altered by disease; the
cause and, if necessary, to be given appropri- changed characteristics may help the physician
ate treatment. to diagnose a disease in the lung.
Vertigo and nausea linked to Menires
disease or following surgery on the middle ear Vestibule
can be hard to treat. HYOSCINE, ANTI- An anatomical term for a cavity positioned at
 762 Vestibulocochlear Nerve

the entrance to a hollow part in the body. An Vinca Alkaloids

example is the nasal vestibule at the entrance of A group of powerful CYTOTOXIC (anticancer)
the NOSE. drugs used to treat acute LEUKAEMIA, LYMPH-
OMA and some solid tumours such as breast and
Vestibulocochlear Nerve lung cancers. Originally derived from the
The eighth cranial nerve. It consists of two sets periwinkle plant, the latest vinca alkaloid
of fibres, which constitute two separate nerves. (VINORELBINE) is a semi-synthetic drug. These
One is known as the vestibular nerve, which alkaloids, which are given intravenously, have
connects the semicircular canals and inner ear potentially serious side-effects on the nervous
to the BRAIN and conveys information on pos- system and also suppress the production of
ture and movement of the body; it is the nerve MYELOID cells in the bone marrow.
of equilibration or balance. The other is
known as the cochlear nerve, which links the Vincents Angina
COCHLEA (organ that responds to sounds) with An ulcerative inflammation of the throat, often
the brain and is the nerve of hearing. Disturb- foul-smelling, and caused by large, spindle-
ance of the former causes giddiness (VERTIGO), shaped bacilli (fusobacterium) and spirilla.
whilst disturbance of the latter causes
DEAFNESS. Vinorelbine
A semi-synthetic vinca alkaloid (see VINCA
Vestibulo-Ocular Reflex ALKALOIDS) CYTOTOXIC drug recently intro-
Eye movement that occurs after or during the duced for the treatment of advanced breast can-
slow injection of 20 ml of ice-cold water into cer, when anthracycline cytotoxic antibiotics
each external auditory meatus (see EAR) in turn. such as DOXORUBICIN have failed. Vinorelbine
is also used to treat advanced non-small-cell
Vestigial lung cancer (see LUNGS, DISEASES OF). As with
An adjective referring to an organ which exists all vinca alkaloids, the drug has neurotoxic
in a rudimentary form and whose function and effects, usually affecting the PERIPHERAL NER-
structure have declined during the course of VOUS SYSTEM and AUTONOMIC NERVOUS SYS-
evolution. An example is the appendix. TEM. It may also cause (reversible) hair loss
(ALOPECIA). The drug is given intravenously.
Viable
The ability of an organism to survive on its Vinyl Ether
own. In the United Kingdom, the legal age of An inhalational anaesthetic used in minor sur-
the viability of a FETUS is 24 weeks. gical procedures of short duration, and for the
induction of ANAESTHESIA for longer surgical
Viagra operations.
See SILDENAFIL CITRATE.
Viraemia
Vibrator A condition occurring at various times in some
(1) An instrument used for vibratory massage to viral infections in which the infecting VIRUS is
improve the tone of muscles and to relax them. present in large amounts in the blood. In other
It is of help in speeding the healing process after viral infections, the organisms are merely trans-
muscle or ligament strains. ported in the blood on their way to target tis-
(2) A penis-shaped, battery-driven device used sues or organs.
by women to attain sexual stimulation and
climax. Viral Haemorrhagic Fever
Also called EBOLA VIRUS DISEASE. A usually
Vibrio fatal infection caused by a virus related to that
V A bacterium with a curved shape, such as the of MARBURG DISEASE. Two large outbreaks of it
vibrio of CHOLERA. were recorded in 1976 (one in the Sudan and
one in Zare), with a mortality, respectively, of
Villus 50 and 80 per cent, and the disease reappeared
One of the minute processes thickly distributed in the Sudan in 1979. After an incubation
upon the inner surface of the small INTESTINE, period of 714 days, the onset is with headache
giving it, to the naked eye, a velvety appearance, of increasing severity, and fever. This is followed
and greatly assisting absorption of digested by diarrhoea, extensive internal bleeding and
food. (See also DIGESTION; ABSORPTION; vomiting. Death usually occurs on the eighth to
ASSIMILATION.) ninth day. Infection is by person-to-person con-
 Vision 763

tact. Serum from patients convalescent from through the pores of collodion filters. They are
the disease is a useful source of ANTIBODIES to responsible for some of the most devastating
the virus. diseases affecting humans: for example, INFLU-
ENZA, POLIOMYELITIS, SMALLPOX and YELLOW
Viral Pneumonia FEVER. The virus of influenza measures 80
Infection of the lung tissue by a VIRUS. Causes nanometres, whereas the STAPHYLOCOCCUS
of this type of pneumonia include ADENOVI- measures 1,000 nanometres (1 nanometre =
RUSES, COXSACKIE VIRUSES and influenza virus. one thousand-millionth of a metre).
Viral infections do not respond to ANTIBIOTICS A single virus particle, known as a virion,
and treatment is symptomatic, with antibiotics comprises an inner core of NUCLEIC ACID which
used only if the patient develops secondary is surrounded by one or two protective cover-
bacterial infection. In a previously healthy ings (capsid) made of protein. Sometimes the
individual the viral infection is usually self- capsid is enclosed by another layer called
limiting, but in vulnerable patients the eld- the viral envelope (also a protein structure).
erly or those with pre-existing disease it can The envelope often disintegrates when the virus
be fatal. invades a cell. Viruses enter cells and then
indulge in a complex and variable process of
Virilisation replication using some of the cells own struc-
The masculinisation of women suffering from ture. Viruses may stay in a hosts nucleus, being
excessive production of the male hormone reactivated months or years later. There are
ANDROGEN. The person develops temporal more than a score of large families of viruses,
balding, a male body shape, increased muscular from papoviruses, which cause WARTS, through
bulk, deepening of the voice, an enlarged CLIT- HERPES viruses (cold sores, CHICKENPOX,
ORIS and HIRSUTISM. Virilisation may also SHINGLES) and orthomyxoviruses (influenza),
occur in women who take synthetic androgens, to corona viruses (common cold) and retro-
a practice sometimes used (illegally) to increase viruses (AIDS/HIV). Viral diseases are more dif-
physical strength and endurance in sport. ficult to treat than those caused by bacteria:
ANTIBIOTICS are ineffective but INTERFERON, a
Virilism group of natural substances, shows promise.
The condition in which masculine character- IMMUNISATION is the most effective way of
istics develop in the female; it is commonly the combating viral infections; smallpox, polio-
result of an overactive suprarenal gland (see myelitis, MUMPS, MEASLES and RUBELLA are
ADRENAL GLANDS), or of a tumour of its cortex. examples of viral diseases which have been suc-
It may also result from an ANDROGEN-secreting cessfully combated. Research is progressing to
ovarian tumour (see OVARIES, DISEASES OF) and find a vaccine against HIV.
also from the POLYCYSTIC OVARY SYNDROME.
The overproduction of male-sex (androgen) Viscera
hormones can produce excess growth of hair, The general name given to the larger organs
male pattern hairline, stopping or disruption of lying within the cavities of the chest and
MENSTRUATION, enlargement of the CLITORIS abdomen. The term viscus is also applied
and conversion to a masculine body shape. individually to these organs.

Virology Vision
The scientific study of viruses (see VIRUS). Broadly speaking, vision is the ability to see.

Virtual Hospital Pathway of light from the eye to the

See HOSPITAL. brain Light enters the EYE by passing through
the transparent cornea, then through the aque-
Virulence ous humour filling the anterior chamber. It V
The power of a bacterium or virus to cause dis- then passes through the pupil, through the lens
ease. Virulence can be measured by how many and the vitreous to reach the retina. In the ret-
people the micro-organism infects, how quickly ina, the rod and cone photoreceptors detect
it spreads through the body, and how many light and relay messages in the form of electro-
people die from it. chemical impulses through the various layers of
the retina to the nerve fibres. The nerve fibres
Virus carry messages via the optic nerve, optic chi-
The term applied to a group of infective agents asma, optic tract, lateral geniculate body and
which are so small that they are able to pass finally the optic radiations to the visual cortex.
 764 Vision, Disorders of

Here in the visual cortex these messages are TESTS OF COLOUR VISION These use specially
interpreted. It is therefore the visual cortex of designed numbers made of coloured dots sur-
the BRAIN that sees. rounded by dots of confusing colour (e.g.
plates).
Visual acuity Two points will not be seen as
two unless they are separated by a minimum Vision, Disorders of
distance. This distance is such that the objects The list of disorders resulting in poor or dim
are so far apart that the lines joining them to the vision is huge. Disturbance of vision can result
eye enclose between them (subtend) an angle of from an uncorrected refractive error, disease or
at least one minute of a degree. This amount of injury of the cornea, iris, lens, vitreous, retina,
separation allows the images of the two points choroid or sclera of the EYE. It may also result
to fall on two separate cones (if the light from from disease or injury to the structures compris-
two points falls on one cone, the two points ing the visual pathway from the retina to the
would be seen as a single point). There are occipital cortex (see VISION Pathway of light
many tests of visual acuity. One of the more from the eye to the brain) and from lesions of
common is the Snellen test type. This is made the structures around the eye for example,
up of many letters of different size. By conven- swollen lids, drooping eyelids. (See EYE, DIS-
tions the chart is placed 6 metres away from the ORDERS OF.)
patient. Someone able to see the lowest line at
this distance has a visual acuity of 6/4. If they Vision, Field of
are only able to see the top letter they have 6/60 When the eye looks at a specific point or object,
vision. Normal vision is 6/6. that point is seen clearly. Other objects within a
large area away from this fixation point can also
Colour vision White light is made up of be seen, but less clearly. The area that can be
component colours. These can be separated by seen around the fixation point, without moving
a prism, thereby producing a spectrum. The the eye, is known as the field of vision. The
three cardinal colours are red, green, and blue; extent of the field is limited inwards by
all other colours can be produced by a varying the nose, above by the brow and below by the
mixture of these three. Colour vision is a com- cheek. The visual field thus has its greatest
plex subject. The trichromat theory of colour extent outwards from the side of the head. The
vision suggests that there are three types of field of vision of each eye overlaps to a large
cones, each type sensitive to one of the cardinal extent so that objects in the centre and towards
colours. Colour perception is based on differen- the inner part of each field are viewed by both
tial stimulation of these cone types. The eyes together. Because the eyes are set slightly
opponent colour theory suggests that each cone apart, each eye sees objects in this overlapping
type can generate signals of the opposite kind. part of the field slightly differently. It is because
Output from some cones can collaborate with of this slight difference that objects can be
the output from others or can inhibit the action perceived as three-dimensional.
of other cones. Colour perception results from Defects in the visual field (scotomas) can be
these various complex interactions. produced by a variety of disorders. Certain of
Defective colour vision may be hereditary or these produce specific field defects. For
acquired, and can occur in the presence of example, GLAUCOMA, some types of brain dam-
normal visual acuity. age and some TOXINS can produce specific
HEREDITARY DEFECTIVE COLOUR VISION is defects in the visual field. This type of field
more common in men (7 per cent of males) defect may be very useful in diagnosing a par-
than women (05 per cent of females). Men are ticular disorder. The blind spot is that part of
affected, but women convey the abnormal gene the visual field corresponding to the optic disc.
(see GENES) to their children. It occurs because There are no rods nor cones on the optic disc
V one or more of the photopigments of the retina and therefore no light perception from this
are abnormal, or the cones are damaged. Red- area. The blind spot can be found temporal (i.e.
green colour defect is the most common. on the outer side) of the fixation point. (See also
ACQUIRED DEFECTIVE COLOUR VISION is the EYE.)
result of disease of the cones or their connec-
tions in the retina, optic nerve or brain for Vision Tests
example, macular disease, optic neuritis. Col- Most vision tests examine a persons sharpness
our vision can be impaired but not lost as a of VISION (visual acuity) and often of the field
result of corneal opacification or cataract forma- of vision (see VISION, FIELD OF). Refraction tests
tion (see under EYE, DISORDERS OF). assess whether a person has an error that can be
 Vivisection 765

corrected with glasses such as ASTIGMATISM, Vitamin

HYPERMETROPIA or MYOPIA. Visual acuity is A term applied to a group of substances which
tested using a Snellen chart when the patient exist in minute quantities in natural foods, and
tries to read letters of differing standard sizes which are necessary to normal nutrition, espe-
from 6 metres away. The optician will prescribe cially in connection with growth and develop-
lenses to correct any defects detected by vision ment. Some A, D, E and K are fat-soluble
tests. and can be stored in the body. The remainder
C, B12 and other members of the B complex
Visual Acuity are water-soluble and are quickly excreted.
See VISION. Most vitamins have now been synthesised.
When they are absent from the food, defective
Visual Evoked Response growth takes place in young animals and chil-
Stimulation of the retina of the EYE with light dren, and in adults various diseases arise; whilst
causes changes in the electrical activity of the short of the production of actual disease, per-
cerebral cortex (see BRAIN). These changes can sistent deprivation of one or other vitamin is
be measured from outside the skull and can give apt to lead to a state of lowered general health.
valuable information about the state of the vis- Certain deficiencies in DIET have long been
ual pathway from the retinal ganglion cells to known to be the cause of SCURVY, BERIBERI,
the occipital cortex. Not only can it determine and RICKETS. A diet containing foods such as
that function is normal, it can also help to milk, eggs, butter, cheese, fat, fish, wholemeal
diagnose some causes of poor VISION. bread, fresh vegetables and fruit should contain
sufficient vitamins. Details of the various vit-
Vital Capacity amins are given in APPENDIX 5: VITAMINS.
The amount of air that can be forcibly exhaled
from the lungs after a deep inspiration. (See Vitiligo
RESPIRATION.)
A disease in which small or large areas of skin
lose their pigment and become white because of
a reduction in the bodys production of
Vital Centres MELANIN. The hair may be similarly affected.
Groups of neurons (see NEURON(E)), usually
Probably a consequence of an autoimmune
sited in the HYPOTHALAMUS and the BRAIN
mechanism, vitiligo is associated with other
stem, that are the control centres for various
autoimmune diseases such as thyroiditis (see
essential body functions. Examples are: blood
THYROID GLAND, DISEASES OF) and ADDISONS
pressure, breathing, heart rate and temperature
DISEASE. There is no cure; the vitiliginous skin
control. The centres are part of the bodys reflex
must be protected from sunburn.
adjustments to the outside world and its
internal environment and are essential in main- Vitreous Body
taining HOMEOSTASIS. A semi-fluid, transparent substance which fills
most of the globe of the EYE behind the lens.
Vitallium
A commercially trademarked alloy of cobalt and Viviparous
chromium used to make instruments, pros- A term used to describe animal groups includ-
theses (see PROSTHESIS), surgical appliances and ing most mammals in which the embryos (see
dentures. Its inert properties make it ideal for EMBRYO) develop inside the mothers body with
use in contact with live tissues such as bone and the young being born alive (in contrast to, say,
muscle. birds and reptiles which hatch from eggs).

Vital Sign Vivisection

An indication that an individual is still alive. For more than a century the medical profession V
Chest movements (resulting from respiration), has aimed at maintaining as high a standard as
the existence of a pulse (showing that the heart possible for vivisection. It was the medical pro-
is still beating) and constriction of the pupil of fession led by Dr James Paget that was respon-
the eye in response to bright light are all vital sible for the passing of the Cruelty to Animals
signs. Other tests such as assessment of brain Act 1876, which aimed to eliminate cruelty.
activity may also be needed in some circum- The infliction of pain was reduced to a min-
stances: for example, when a patient is on a life- imum by the use of anaesthetics (see ANAES-
support machine. (See also GLASGOW COMA THESIA), and the licensing and surveillance of
SCALE.) animal experiments was ensured.
 766 Vocal Cords

Most experiments are carried out on specially In any given voice, the range of pitch seldom
bred mice and rats. Fewer than 1 per cent are exceeds two and a half octaves. Typically, the
done on cats, dogs, non-human primates, farm small larynx of childhood produces a shrill or
animals, frogs, fish and birds. Control on treble voice; the rapid growth of the larynx
experiments has recently been strengthened. around PUBERTY causes the voice to break in
The great majority of animal experiments are boys. Changes in the voice also occur at other
done without anaesthesia because feeding ages as a result of the secondary action of the
experiments, taking blood, or giving injections SEX HORMONES. Generally speaking, the adult
does not require anaesthetics in animals any voice is bass and tenor in men, contralto or
more than in humans. Universities in Britain soprano in women. Timbre is due to differences
are responsible for fewer than one-fifth of ani- in the larynx, as well as to voluntary changes in
mal experiments; commercial concerns and the shape of the mouth.
government institutions are responsible for
most of the rest. Tests on cosmetics account for Speech Rapid modifications of the voice,
under 1 per cent of all animal work, but are produced by movements of the PALATE, tongue
necessary because such materials are often and lips. Infants hear the sounds made by
applied with great frequency and for a long others and mimic them; hence the speech
time to the skin of adults and infants. centres in the BRAIN are closely connected with
The use of tissue cultures and computer those of hearing.
models instead of live animals are methods of
research and investigation that are being Defects of speech See below, and also SPEECH
increasingly used. There is, however, a limit to DISORDERS.
the extent to which infection, cancer, or drugs MUTISM, or absence of the power to speak, may
can be investigated on cultures of tissue cells. be due to various causes. LEARNING DISABILITY
Computerised or mathematical modelling of that prevents the child from mimicking the
experiments is probably the most promising actions of others is most common; in other
line of development. cases the child has normal intelligence but some
neurological disorder, or disorder of the speech
Vocal Cords organs, is responsible. Alternatively, complete
See LARYNGOSCOPE; LARYNX; VOICE AND DEAFNESS or early childhood ear disease may be
SPEECH. the cause.
STAMMERING is a highly individual condition,
Vocal Resonance but is basically a lack of coordination between
The air carrying the voice produced in the LAR- the different parts of the speech mechanism.
YNX passes through the throat, mouth and nose. (See also main entry on STAMMERING.)
The shape and size of these structures will influ- DYSPHASIA is the inability to speak or under-
ence the timbre of the voice, or vocal resonance. stand speech, most commonly following brain
This will vary from person to person and even disease, such as STROKE.
within an individual; for example, with a cold. APHONIA or loss of voice may be caused by
LARYNGITIS or, rarely, a symptom of conversion
Voice and Speech and dissociative mental disorders traditionally
Terms applied to the sounds produced in the referred to as HYSTERIA. It is generally of short
upper AIR PASSAGES which form one of the duration.
means of communication between human
beings. Air passes through the LARYNX to pro- Volar
duce the fundamental notes and tones known A term relating to the palm or sole.
as voice. This is then modified during its pas-
sage through the mouth so as to form speech or Volkmanns Contracture
V song. A rare condition in which, as a result of too
great a pressure from splint or bandage in the
Voice This has three varying characteristics: treatment of a broken arm, the flexor muscles of
loudness, pitch, and quality or timbre. Loud- the forearm contract and thus obstruct free flow
ness depends on the volume of air available and of blood in the veins; the muscles then swell
therefore on the size of the chest and the and ultimately become fibrosed.
strength of its muscles. Pitch is determined by
larynx size, the degree of tenseness at which the Voluntary Admission
vocal cords are maintained, and whether the The term applied in the UK to the admission of
cords vibrate as a whole or merely at their edges. a mentally ill person to a psychiatric unit with
 Von Willebrands Disease 767

his or her agreement. Patients with mental ill- cause: for example, a blow on the head, a cere-
nesses that may endanger their own safety or bral tumour, a cerebral abscess, meningitis.
that of others can be compulsorily admitted Nausea and vomiting are common symptoms
using special legal powers this is traditionally that may arise from local disease of the gastro-
called sectioning. (See MENTAL ILLNESS.) intestinal tract, but they are also associated with
systemic illness for example, DIABETES MEL-
Voluntary Muscle LITUS or kidney failure (see KIDNEYS, DISEASES
Also known as skeletal muscle, this forms the OF) and also with disturbances of labyrinthine
muscles which are under a persons conscious function, such as motion sickness and acute
control. Muscles that control walking, talking labyrinthitis.
and swallowing are examples of those under
such control (see INVOLUNTARY MUSCLE; Treatment The cause of the vomiting must
MUSCLE; NERVOUS SYSTEM). be sought and treatment directed towards this.
Symptomatic treatment for vomiting can be
Volvulus dangerous since accurate diagnosis of the cause
An obstruction of the bowels produced by the may be hindered. If antinauseant drug treat-
twisting of a loop of bowel round itself. (See also ment is indicated, the choice of drug depends
STRANGULATION; INTESTINE, DISEASES OF.) on the cause of the vomiting.
Granisetron and ondansetron are 5-
Vomiting hydroxytryptamine (5HT3) antagonists valu-
Vomiting means the expulsion of the STOMACH able in the treatment of nausea and vomiting
contents through the mouth. When the effort induced by cytotoxic CHEMOTHERAPY or
of vomiting is made, but nothing is brought up, RADIOTHERAPY and prevention and treatment
the process is known as retching. When vomit- of post-operative nausea and vomiting.
ing occurs, the chief effort is made by the Prochlorperazine is valuable in the treatment of
muscles of the abdominal wall and by the dia- severe nausea, vomiting, VERTIGO and disorders
phragm contracting together and squeezing the of the LABYRINTH of the EAR, although extra-
stomach. The contraction of the stomach wall pyramidal symptoms may occur, particularly in
is no doubt also a factor, and an important step children, elderly and debilitated patients.
in the act consists in the opening at the right Vomiting may occur after surgical operations
moment of the cardiac or upper orifice of the and this is due to the combined effects of
stomach. This concerted action of various analgesics, anaesthetic agents and the psycho-
muscles is brought about by a vomiting centre logical stress of operation. Various drugs can be
situated on the floor of the fourth ventricle in used to prevent or stop post-operative
the BRAIN. vomiting.
Nausea and vomiting are common symp-
Causes Vomiting is brought about by stimu- toms in pregnancy. Drugs are best avoided in
lation of this nervous centre, and in most cases this situation as they may damage the develop-
this is effected through sensations derived from ing FETUS. Simple measures, such as the taking
the stomach itself. Thus, of the drugs which of food before getting up in the morning and
cause vomiting, some act only after being reassurance, are often all that is necessary.
absorbed into the blood and carried to the
brain, although most are irritants to the mucous Von Recklinghausens Disease
membrane of the stomach (see EMETICS); vari- An inherited disease, now called neurofibroma-
ous diseases of the stomach, such as cancer, tosis. About one case occurs every 3,000 live
ulcer and food poisoning act in a similar way. births. The disease is characterised by tumours
Stimulation not only of the nerves of the along the course of nerves which can be felt
stomach, but also of those supplying other beneath the skin. Soft tumours may also
abdominal organs produces vomiting; thus in develop beneath the skin. The condition may V
obstruction of the bowels, peritonitis, gall-stone have other associated abnormalities such as
colic, renal colic, and even in some women dur- SCOLIOSIS, decalcification of the bones due to
ing pregnancy, vomiting is a prominent overactivity of the PARATHYROID glands, and
symptom. fibrosis in the lungs. Surgery may be needed for
Severe emotional shock may cause vomiting, cosmetic reasons or to relieve pressure on the
as may acute anxiety and unpleasant experi- nervous system.
ences such as seeing an accident, suffering
severe pain or travel sickness. Von Willebrands Disease
Direct disturbance of the brain itself is a A genetically determined blood disorder in
 768 Voyeurism

which the affected person suffers episodes of folds extend upwards as an arch over the CLIT-
spontaneous bleeding similar to that occurring ORIS. The vulva also contains vestibular glands
in people with HAEMOPHILIA. It may be associ- which provide profuse mucoid secretions
ated with a lack of FACTOR VIII (see COAGULA- during sexual activity.
TION) in the blood. The disorder is inherited as
an autosomal dominant gene (see GENETIC Vulvectomy
DISORDERS). Surgical excision of the external genitals (see
VULVA). In simple vulvectomy the LABIA majora
Voyeurism and minora and the CLITORIS are surgically
The regular viewing of people who are naked or removed, usually to treat a non-malignant
part-naked or who are taking part in intimate growth. A more extensive operation is radical
sexual activities. The voyeurs subjects are vulvectomy in which there is wide excision of
unaware that they are being watched. The voy- the two labia and the clitoris along with com-
eur, nearly always a man, usually becomes sexu- plete removal of all regional LYMPH NODES on
ally excited and may induce ORGASM by both sides and the covering skin. This pro-
MASTURBATION. cedure is carried out to treat cancer of the vulva.

Vulva Vulvo-Vaginitis
The external genitalia of the female. The LABIA Inflammation of the VULVA and VAGINA. It may
majora and minora comprising folds of flesh, be due to infection, and may be a presenting
the latter inside the former surround the feature of late onset DIABETES MELLITUS.
openings of the VAGINA and URETHRA. The Trauma may sometimes be the cause.

V
 from the SKIN arising from the epidermis and

W caused by various subtypes of human papil-

loma virus. The causal viruses are ubiquitous
and most people probably harbour them.
Whether or not warts develop depends upon
age, previous infection and natural resistance.

Waiting List Common warts (verruca vulgaris) are

A term widely used in the NHS to show the seen mainly in children and young adults on
number of people waiting for hospital admis- the backs of the fingers and hands, and less
sion, usually for non-acute surgery. The size of often on the knees, face or scalp. They may be
the waiting list has come to be perceived over single or numerous and range from 1 mm to 10
the past 20 years especially by politicians as a mm or more in size. Untreated, they often
measure of the Services effectiveness. To the resolve spontaneously after weeks or months.
individual patient, however, what matters is the They may be occupationally contracted by
waiting time how long they have to wait butchers and meat-handlers.
before admission. This figure along with the
time a patient has to wait for an outpatient Plane warts (verruca plana) are small,
appointment to see a consultant is increas- flat-topped, yellowish papules seen mainly on
ingly being recognised as one important meas- the backs of the hands, wrists and face in young
urement of how well a hospital is serving its people. They may persist for years.
local communities.
Digitate warts (verruca digitata) are
Walk finger- or thread-like warts up to 5 mm in
See GAIT.
length with a dark rough tip. They tend to grow
Warfarin on the eyelids or neck.
An anticoagulant (see ANTICOAGULANTS), usu-
ally given by mouth on a daily basis. The initial Plantar warts (verruca plantaris) oc-
dose depends upon the PROTHROMBIN or cur on the soles of the feet, most commonly in
coagulation time; this should be determined older children, adolescents and young adults.
before starting treatment, and then at regular Spread by walking barefoot in swimming pools,
intervals during treatment. It is indicated for changing rooms, etc., these warts may appear as
the prophylaxis of embolisation (see EMBOLISM) minor epidemics in institutions, such as
in rheumatic heart disease and atrial fibrillation schools. They are flattened, yellow-white dis-
(see HEART, DISEASES OF); after prosthetic heart- crete lesions in the sole or heel, tender when
valve insertion; prophylaxis and treatment of squeezed. Multiple black points in the wart are
venous thrombosis and PULMONARY EMBOL- thrombosed capillaries. Occasionally, aggregates
ISM; and TRANSIENT ISCHAEMIC ATTACKS OR of plantar warts form a mosaic-like plaque,
EPISODES (TIA, TIE). When given in tablet form, especially in chronically warm, moist feet.
its maximum effect generally occurs within
about 36 hours, wearing off within 48 hours. Genital warts are sexually transmitted. In
Special caution is appropriate in patients with the male they occur on the shaft of the PENIS
disease of the liver or kidneys or who have had and on the PREPUCE or around the anus. In
recent surgery. Warfarin is contra-indicated women they occur around the entrance to the
throughout pregnancy (especially the first and VAGINA and LABIA minora. Genital warts vary
third trimesters), and in cases of PEPTIC ULCER, from 12 mm pink papules to florid,
severe HYPERTENSION and bacterial ENDO- cauliflower-like masses. Pregnancy facilitates
CARDITIS. The most important adverse effect is their development.
HAEMORRHAGE. Other reported side-effects
include HYPERSENSITIVITY, rash, ALOPECIA, Mucosal warts may develop on the
diarrhoea, unexplained drop in HAEMATOCRIT mucous membranes of the mouth.
readings, purple toes, skin NECROSIS, JAUN-
DICE, liver dysfunction, nausea, vomiting and Laryngeal warts may be found in children
pancreatitis (see PANCREAS, DISEASES OF). (See whose mothers had genital warts (see above) at
also COAGULATION.) the time of delivery. Some subtypes of genital
wart can infect the uterine cervix (see UTERUS),
Warts causing changes which may lead eventually to
Warts (verrucae) are small, solid outgrowths cancer.
 770 Washing

Treatment CRYOTHERAPY freezing with with incompetence of the AORTIC VALVE of the
liquid nitrogen is the principal weapon heart.
against all types of warts, but curettage (scrap-
ing out the wart with a CURETTE) and cauterisa- Water Intoxication
tion (see ELECTROCAUTERY) or LASER therapy A disorder resulting from excessive retention of
may be required for resistant warts. Genital water in the brain. Main symptoms are dizzi-
warts may respond to local application of ness, headaches, confusion and nausea. In
PODOPHYLLIN preparations. Sexual partners severe cases the patient may have fits (see SEIZ-
should be examined and treated if necessary. URE) or lose consciousness. Several conditions
Finally, treatment of warts should not be more can disturb the bodys water balance causing
onerous or painful than the disease itself, since accumulation of water in the tissues. Heart or
spontaneous resolution is so common. kidney failure, CIRRHOSIS of the liver and dis-
orders of the ADRENAL GLANDS can all result in
Washing water retention. Other causes are stress as a
See DISINFECTION. result of surgery, when increased secretion of
antidiuretic hormone (VASOPRESSIN) by the
Washing Out of the Stomach adrenal gland may occur. Treatment is of the
See GASTRIC LAVAGE. underlying condition and the judicious use of
DIURETICS, with careful monitoring of the

Wassermann Reaction bodys ELECTROLYTES.

A test introduced for the diagnosis of SYPHILIS
by examination of the blood. It has now been Wax
largely supplanted by other, more specific tests. This is used in medicine as an ingredient of
ointments, plasters, and suppositories (see SUP-
POSITORY). It is used either as yellow wax
Wasting derived directly from honeycomb, or as white
See ATROPHY.
wax, which is the same substance bleached. It is
also used in the form of paraffin wax to apply
Water Bed heat in the relief of rheumatic pains.
A bed with a water-filled mattress can help For wax in the ear, see under EAR, DISORDERS
prevent bed sores (see ULCER Decubitus ulcer) OF.
in patients confined to bed for more than a few
days. Its flexibility provides uniform support Weakness
for the whole body. Air beds are now more See ATROPHY; CACHEXIA; PARALYSIS; TONICS.
often used: they are light and more comfort-
able and the modern version, called a ripple Weals
bed, has a little motor that fills and empties Or wheals: raised white areas of OEDEMA in the
tubes in the mattress. The patients circulation skin with reddened margins, which may result
is stimulated and pressure is regularly changed from sharp blows, or accompanied by itching,
on susceptible parts of the body elbows, but- may be a symptom of URTICARIA.
tocks and heels thus reducing the likelihood
of pressure sores developing, particularly in the Weaning
elderly. The process by which a baby is introduced to
solid foods after having only had breast milk or
Waterbrash artificial milk to drink. The transfer usually
Also called pyrosis. A symptom of indigestion; starts at around 45 months of age but many
during the course of DIGESTION, the mouth fills parents prefer not to wait. (See INFANT
with tasteless or sour fluid, which is generally FEEDING.)
saliva, but is sometimes brought up from the
stomach. This is accompanied by a burning Webbed Fingers
W pain often felt at the pit of the stomach or in the Or toes see also SYNDACTYLY. A deformity
chest. The condition is a symptom of excessive sometimes present at birth, and which tends to
acidity of the stomach contents, due sometimes run in families. The web may be quite a thin
to an injudicious diet, and often characteristic structure, or the fingers may be closely united
of a DUODENAL ULCER. (See also DYSPEPSIA.) by solid tissue. In any case, separation is a mat-
ter of considerable difficulty, because, if the web
Water-Hammer Pulse is simply divided, it heals up as before. A special
The peculiarly sudden PULSE that is associated operation is necessary, consisting in turning
 Wernickes Encephalopathy 771

back a flap of the web upon each of the united gested that this increase, and earlier maturation,
fingers, or some other device to produce healing have been due to a combination of genetic mix-
in the new position. ing as a result of population movements, with
the whole range of improvement in environ-
Webers Test mental hygiene and not merely to better
A test with a tuning fork that is used to assess a nutrition.
persons DEAFNESS. In the case of adults, views have changed in
recent years concerning ideal weight. Life-
Weight and Height insurance statistics have shown that maximal
Charts relating height to age have been devised, life expectancy is obtained if the average weight
and give an indication of the normal rate of at 2530 years is maintained throughout the
growth. (See APPENDIX 6: MEASUREMENTS IN rest of life. These insurance statistics also sug-
MEDICINE for more details.) The wide variation gest that it is of advantage to be slightly over the
in normal children is immediately apparent on average weight before the age of 30 years; to be
studying such charts. Deviations from the mean of average weight after the age of 40; and to be
of this wide range are called percentiles. Centile underweight from ages 3040. In the past it has
or percentile charts describe the distribution of been usual, in assessing the significance of an
a characteristic in a population. They are adults weight, to allow a 10 per cent range on
obtained by measuring a specific characteristic either side of normal for variations in body-
in a large population of at least 1,000 of each build. A closer correlation has been found
sex at each age. For each age there will be a between thoracic and abdominal measurements
height, above and below which 50 per cent of and weight.
the population lies: this is called the 50th cen-
tile. The 50th centile thus indicates the mean Weights and Measures
height at a particular age. Such tables are less It is more than a hundred years since the metric
reliable around the age of PUBERTY, because of system was legalised in Britain, but it was not
variation in age of onset. until 1969 that it became illegal to use any sys-
Minor variations from the mean do not war- tem of weights and measures other than the
rant investigation, but if the height of an indi- metric system for dispensing prescriptions.
vidual falls below the third centile (3 per cent of A rationalisation of the metric system is now
normal children have a height that falls below used, known as the International System of
the third centile) or above the 97th centile, Units (SI see APPENDIX 6: MEASUREMENTS IN
investigation is required. Changes in the rate of MEDICINE).
growth are also important, and skeletal propor-
tions may provide useful information. There Weils Disease
are many children who are normal but who are See LEPTOSPIROSIS.
small in relation to their parents; the problem is
merely growth delay. These children take longer Werners Syndrome
to reach maturity and there is also a pro- A rare inherited condition in which the
portional delay in their skeletal maturation so affected person suffers from premature ageing
that the actual height must always be assessed in from adolescence onwards. His or her growth
relation to maturity. The change in skeletal may be retarded, the skin become thin, and
proportions is one manifestation of maturity, arterial disease, DIABETES MELLITUS and leg
but other features include the maturing of facial ulcers (see ULCER) develop. Treatment is
features with the growth of nose and jaw, and symptomatic.
dental development. Maturity of bone can read-
ily be measured by the radiological bone age. Wernickes Encephalopathy
Failure to gain weight is of more significance. Also called the Wernicke-Korsakoff syndrome,
Whilst this may be due to some underlying dis- this uncommon disorder is characterised by
ease, the most common cause is a diet contain- mental confusion or DELIRIUM that occurs in
ing inadequate calories (see CALORIE). Over the combination with an unsteady GAIT, nystagmus W
last six decades or so there has been quite a (see under EYE, DISORDERS OF), and paralysis of
striking increase in the heights and weights of the eye muscles and eventually PSYCHOSIS. It is
European children, with manufacturers of chil- caused by a deficiency of vitamin B1 (THIAMINE
drens clothing, shoes and furniture having to see APPENDIX 5: VITAMINS) which affects the
increase the size of their products. Growth is brain and nervous system. It occurs in alcoholic
now completed at 2021 years, compared with individuals and in patients with persistent
25 at the turn of the century. It has been sug- vomiting. As soon as the condition is
 772 Werthheims Hysterectomy

diagnosed, it must be treated with large doses of patient usually recovers fully but may take sev-
thiamine. Unless the patient has developed eral weeks to do so.
symptoms of psychosis, the condition is usually
reversible with treatment. Whipworm
A popular name for Trichuris trichiura. (See also
Werthheims Hysterectomy TRICHURIASIS.)
A major operation done to remove cancer of the
UTERUS or ovary (see OVARIES). The ovaries, White Blood Cell
FALLOPIAN TUBES, the uterus and its ligaments, See LEUCOCYTES.
the upper VAGINA, and the regional LYMPH
NODES are all excised. White Finger
Spasm of the blood vessels in the finger, result-
West Nile Virus ing in a white appearance. The condition is
A mosquito-borne viral infection that is nor- common in RAYNAUDS DISEASE but it can be
mally harmless to healthy people who, if caused by the long-term use of percussion
infected, develop a mild flu-like illness. How- implements such as mechanical road drills or
ever, if the elderly and those in poor health, hammers. It is a recognised industrial disease.
particularly immunocompromised patients, are Treatment is to remove or treat the underlying
infected, they may develop fatal inflammation cause.
of the brain and spinal cord. In Israel in 2000,
12 people died and more than 155 survived an White Hair
outbreak; and in New York in 1999, more than The greying or whitening of hair which takes
60 people were infected, of whom six died. The place with age is due to a loss of its pigment,
disease was first reported in Uganda in 1937 MELANIN, and the collection of air bubbles in
and became ENDEMIC in the Middle East and the shaft of the hair. There is no evidence that
Africa, recently spreading to Europe, central hair ever goes white overnight, whether in
Asia, Oceania and America. Mosquitoes bear- response to shock, strain or any other cause.
ing the flaviviridae-family virus usually contract Rapid whitening may occur patchily in a matter
it by biting infected poultry, but the infection of days, but it is more often a matter of weeks or
has been found in mammals, such as cats, dogs months. In the more rapid cases the cause is
and horses. thought to be a form of ALOPECIA in which the
dark hairs which fall out are replaced by white
Wheals hairs. An alternative cause is VITILIGO. Certain
See WEALS. drugs, including mephenesin and CHLORO-
QUINE, may also cause whitening of the hair.
Wheezing
A popular name applied to the various sounds Whitehead
produced in the chest when the bronchial tubes A common benign blemish of the skin (see
are narrowed. It is applied particularly to the MILIA).
long-drawn breathing of ASTHMA, and to the
whistling or purring noises that accompany Whitlow
breathing in cases of BRONCHITIS. A popular term for PARONYCHIA.

Whiplash Injury Whooping-Cough

An injury to the neck region caused by the neck Whooping-cough, or pertussis, is a respiratory-
being forcibly bent backwards and forwards (or tract infection caused by Bordetella pertussis and
the other way around). Car accidents are a spread by droplets. It may occur at all ages, but
common cause, when a driver or passenger is around 90 per cent of cases are children aged
suddenly decelerated. The injury usually affects under five. Most common during the winter
the ligaments, spinal joints and soft tissues of months, it tends to occur in epidemics (see EPI-
W the neck. Subluxation (partial dislocation) of a DEMIC), with periods of increased prevalence
cervical joint sometimes occurs and cervical occurring every three to four years. It is a notifi-
vertebra may occasionally be fractured if the able disease (see NOTIFIABLE DISEASES). The rou-
forces are severe. Pain and stiffness of the neck tine vaccination of infants with TRIPLE VACCINE
result and these may worsen after a day or so. (see also VACCINE; IMMUNISATION), which
Treatment includes immobilisation of the neck includes the vaccine against whooping-cough,
in a collar, and analgesic and muscle-relaxing has drastically reduced the incidence of this
drugs. PHYSIOTHERAPY may be necessary. The potentially dangerous infection. In the 1990s
 Winter Vomiting Disease 773

over 90 per cent of children in England had Widal Reaction

been vaccinated against whooping-cough by See AGGLUTINATION.
their second birthday. In an epidemic of
whooping-cough, which extended from the last Wilms Tumour
quarter of 1977 to mid-1979, 102,500 cases of Also called nephroblastoma. This is the com-
whooping-cough were notified in the United monest kidney tumour in infancy. It is a malig-
Kingdom, with 36 deaths. This was the biggest nant tumour, which occurs in around one per
outbreak since 1957 and its size was partly 10,000 live births. The survival rate with mod-
attributed to the fall in vaccination acceptance ern treatment (removal of the kidney followed
rates because of media reports suggesting that by radiotherapy and chemotherapy) is now
pertussis vaccination was potentially dangerous around 80 per cent.
and ineffective. In 2002, 105 cases were noti-
fied in England.
Wilsons Disease
Symptoms The first, or catarrhal, stage is Wilsons disease, or hepatolenticular degener-
characterised by mild, but non-specific, symp- ation, is a familial disease in which there is an
toms of sneezing, conjunctivitis (see under EYE, increased accumulation of COPPER in the liver,
DISORDERS OF), sore throat, mild fever and
brain, and other tissues including the kidneys.
cough. Lasting 1014 days, this stage is the Its main manifestation is the development of
most infectious; unfortunately it is almost tremor and rigidity, with difficulty in speech. In
impossible to make a definite clinical diagnosis, many cases there is improvement following the
although analysis of a nasal swab may confirm a administration of dimercaprol, penicillamine,
suspected case. This is followed by the second, or trientine dihydrochloride; these substances
or paroxysmal, stage with irregular bouts of cause an increased excretion of copper.
coughing, often prolonged, and typically more
severe at night. Each paroxysm consists of a Windpipe
succession of short sharp coughs, increasing in The popular name for the TRACHEA, which
speed and duration, and ending in a deep, crow- extends from the LARYNX above to the point in
ing inspiration, often with a characteristic the upper part of the chest where it divides into
whoop. Vomiting is common after the last the two large bronchial tubes, one to each lung.
paroxysm of a series. Lasting 24 weeks, this It is about 10 cm (4 inches) in length and con-
stage is the most dangerous, with the greatest sists of a fibrous tube kept permanently open by
risk of complications. These may include about 20 strong, horizontally placed hoops of
PNEUMONIA and partial collapse of the lungs, cartilage, each of which forms about two-thirds
and fits may be induced by cerebral ANOXIA. of a circle, the two ends being joined behind by
Less severe complications caused by the stress muscle fibres. This fibrocartilaginous tube is
of coughing include minor bleeding around lined by a smooth mucous membrane, richly
the eyes, ulceration under the tongue, HERNIA supplied with mucous glands and covered by a
and PROLAPSE of the rectum. Mortality is single layer of ciliated epithelium. (See also AIR
greatest in the first year of life, particularly PASSAGES.)
among neonates infants up to four weeks
old. Nearly all patients with whooping-cough Winter Vomiting Disease
recover after a few weeks, with a lasting Winter vomiting disease, or epidemic nausea
IMMUNITY. Very severe cases may leave struc- and vomiting, is a condition caused by sub-
tural changes in the lungs, such as EMPHY- types of the genus Norwalk-like virus and is
SEMA, with a permanent shortness of breath or characterised by nausea, vomiting, diarrhoea
liability to ASTHMA. and giddiness, which occurs during the winter.
Outbreaks of it usually involve whole families
Treatment Antibiotics, such as ERYTHROMY- or may affect communities like schools. The
CIN or TETRACYCLINES, may be helpful if given incubation period is 2448 hours, and attacks
during the catarrhal stage largely in prevent- seldom persist for more than 72 hours. In W
ing spread to brothers and sisters but are of no England and Wales in 2000, more than 1,600
use during the paroxysmal stage. Cough sup- infections were reported compared to more
pressants are not always helpful unless given in than 16,400 cases of salmonella infections and
high (and therefore potentially narcotic) doses, 56,420 of CAMPYLOBACTER. However, in Eng-
and skilled nursing may be required to main- land it is estimated that around 1,500 times
tain nutrition, particularly if the disease is pro- more people are infected in the community
longed, with frequent vomiting. than are reported. Humans are the only
 774 Wisdom Tooth

known hosts of the virus and infection can be (UTERUS), such as the beating of the mothers
acquired via contaminated food or water or, heart, the bowel sounds of the baby and the
more commonly, from an infected individual like. The claim is that the replaying of these
via the faeco-oral route, aerosol-spread and brings back the peaceful music of the womb,
FOMITES. to which they have become conditioned, and
thus sings them to sleep.
Wisdom Tooth
A popular name for the last molar tooth on Wool-Sorters Disease
either side of each jaw (see TEETH). These teeth Another name for ANTHRAX.
are the last to appear and should develop in
early adult life, but often they do not cut the Word Blindness
gum till the age of 20 or 25; indeed, they may Alexia: a condition in which, as the result of
sometimes remain permanently impacted in the disease in the brain, a person becomes unable to
jaw-bone. This occurs in up to 25 per cent of associate their proper meanings with words,
individuals. The lower third molar is often although he or she may be quite able to spell the
impacted against the second because of the dir- letters.
ection in which it erupts.
Word deafness is an associated condition
Witch-Hazel in which, although hearing remains perfect, the
A preparation of the bark, twigs, and dried patient has lost the power of referring the
leaves from Hamamelis virginiana, a plant names heard to the articles they denote. (See also
found in the United States. It has strong astrin- DYSPHASIA.)
gent properties and is used to check haemor-
rhages and excessive mucous discharges, and World Medical Association
also for piles (see HAEMORRHOIDS). See ETHICS.

Withdrawal Bleeding Worms

Loss of blood from the UTERUS via the VAGINA See ASCARIASIS; ENTEROBIASIS; TAENIASIS.
occurring when the womens level of oestrogen
hormones (OESTROGENS), PROGESTERONE Wounds
hormone or PROGESTOGEN drugs falls quickly. A wound is any breach suddenly produced in
The withdrawal bleeding that happens at the the tissues of the body by direct violence. An
end of each months cycle of combined oral extensive injury of the deeper parts without cor-
contraceptive pills (see CONTRACEPTION) imi- responding injury of the surface is known as a
tates the womans menstrual period (see MEN- bruise or contusion.
STRUATION) but is normally briefer and less in
amount. Varieties These are classified according to
the immediate effect produced:
Withdrawal Symptoms INCISED WOUNDS are usually inflicted with
Unpleasant physical and mental symptoms that some sharp instrument, and are clean cuts, in
occur when a person stops using a drug or sub- which the tissues are simply divided without
stance on which he or she is dependent (see any damage to surrounding parts. The bleeding
DEPENDENCE). The symptoms include tremors, from such a wound is apt to be very free, but
sweating, and vomiting which are reversed if can be readily controlled.
further doses are given. Alcohol and hard drugs, PUNCTURE WOUNDS, or stabs, are inflicted with
such as morphine, heroin, and cocaine, are a pointed instrument. These wounds are dan-
among the substances that induce dependence, gerous, partly because their depth involves the
and therefore withdrawal symptoms, when danger of wounding vital organs; partly because
stopped. Amphetamines and nicotine are other bleeding from a stab is hard to control; and
examples. partly because they are difficult to sterilise. The
W wound produced by the nickel-nosed bullet is a
Womb puncture, much less severe than the ugly lacer-
See UTERUS. ated wound caused by an expanding bullet, or
by a ricochet, and, if no clothing has been car-
Womb Music ried in by the bullet, the wound is clean and
The name given to the playing to crying babies usually heals at once.
of sounds comparable to those by which the LACERATED WOUNDS are those in which tissues
unborn babe is surrounded in the womb are torn, such as injuries caused by machinery.
 Wry-Neck 775

Little bleeding may occur and a limb can be Those in the row nearest the hand are the tra-
torn completely away without great loss of pezium, trapezoid, capitate and hamate. These
blood. Such wounds are, however, especially latter articulate with the metacarpal bones in
liable to infection. the hand and are closely bound to one another
CONTUSED WOUNDS are those accompanied by short, strong ligaments; and the wrist-joint is
by much bruising of surrounding parts, as in the union of the composite mass thus formed
the case of a blow from a cudgel or poker. There with the RADIUS and ULNA in the forearm. The
is little bleeding, but healing is slow on account wrist and the radius and ulna are united by
of damage to the edges of the wound. Any of strong outer and inner lateral ligaments, and by
these varieties may become infected. weaker ligaments before and behind, whilst the
powerful tendons passing to the hand and
First-aid treatment The first aim is to fingers strengthen the wrist.
check any bleeding. This may be done by pres- The joint can move in all directions, and its
sure upon the edges of the wound with a clean shape and many ligaments mean that it rarely
handkerchief, or, if the bleeding is serious, by dislocates although stretching or tearing of
putting the finger in the wound and pressing it some of these ligaments is a common accident,
upon the spot from which the blood is coming. constituting a sprain. (See JOINTS, DISEASES OF.)
If medical attention is available within a few Inflammation of the tendon-sheaths may occur
hours, a wound should not be interfered with as a result of injury or repetitive movement (see
further than is necessary to stop the bleeding UPPER LIMB DISORDERS). A fairly common
and to cover it with a clean dry handkerchief or condition is the presence of a GANGLION, in
bandage. When expert assistance is not soon which an elastic swelling full of fluid develops
obtainable, the wound should be cleaned with on the back or front of the wrist in connection
an antiseptic such as CHLORHEXIDINE or boiled with the sheaths of the tendons. (See also HAND.)
water and the injured part fixed so that move-
ment is prevented or minimised. A wounded Wrist-Drop
hand or arm is fixed with a SLING, a wounded See DROP WRIST.
leg with a splint (see SPLINTS). If the victim is in
SHOCK, he or she must be treated for that. (See Writers Cramp
also APPENDIX 1: BASIC FIRST AID.) A SPASM which affects certain muscles when a
person is writing, and which may not occur
Wrinkle when the same muscles are employed in other
A natural furrow in the skin commonly associ- acts. Similar symptoms are observed in the case
ated with AGEING. Wrinkles are most promin- of musicians (guitar, clarinet and piano in par-
ent on the face and other exposed body parts. ticular), typists, word-processor and computer
Overexposure to sunlight causes premature operators and artists.
wrinkling. Cosmetic preparations may tempor-
arily improve excessive wrinkling, but a face lift, Wry-Neck
which stretches the skin using surgery, can A condition in which the head is twisted to one
improve a persons face for up to five years. side. It may be caused by the contraction of a
scar, such as that resulting from a burn or by
Wrist paralysis of some of the muscles; as a result of
The joint situated between the arm above and injury at birth; or trauma to the area later in
the hand below. The region of the wrist con- life. Treatment is by an orthopaedic collar, heat
tains eight small carpal bones, arranged in two or ULTRASOUND, or PHYSIOTHERAPY. Some-
rows, each containing four bones. Those in the times a local injection of BOTULISM toxin will
row nearest the forearm are from the outside produce temporary relief. Rarely, surgery is
inwards when looking at the palm of the hand necessary. (See also MUSCLES, DISORDERS OF
the scaphoid, lunate, triquetrum, and pisiform. Cramp; SPASMODIC TORTICOLLIS.)

W
 Xenograft

X A transplant (see TRANSPLANTATION) from one

animal to another of a different species. It is also
known as a heterograft.

Xenotransplantation
TRANSPLANTATION of organs from one species
Xanthelasma Palpebrarum to another for example, from pigs to humans.
These yellow smooth nodules of LIPID-laden The use of organs from appropriately cloned
cells occur in and around the eyelids (see EYE). animals was seen as a possible solution to the
Blood lipids are usually normal, but there is an shortage of human organs for transplantation;
association with hypercholesterolaemia (see however, research has shown that rejection
CHOLESTEROL; HYPERLIPIDAEMIA) in a minor- remains a problem and there is also an
ity of sufferers. unresolved possibility that diseases might be
transmitted across the species barrier. It seems
Xanthoma likely that STEM CELL research will provide a
(Plural: xanthomata.) A deposit of fatty more realistic source of tissues for transplanta-
material in the skin, subcutaneous fat and tion to replace diseased organs in humans.
tendons. The presence of a xanthoma may be
the first sign that a person has primary or Xeroderma
secondary HYPERLIPIDAEMIA a raised con- The term means dry skin. Normal skin may
centration of lipids (see LIPID) in the blood. become dry when exposed to very low ambient
This can lead to ATHEROMA, and appropriate humidity and is then vulnerable to irritation
clinical and laboratory examinations should by soaps, detergents and other chemicals
be done to determine the diagnosis and which cause chapping. Dryness of the skin
treatment. may also be a feature of skin disease, especially
When fatty deposits occur in various parts of atopic eczema (see ATOPY; DERMATITIS). Genet-
the body skin, brain, cornea, internal organs ically determined xeroderma is called
and tendons the condition is called xan- ICHTHYOSIS.
thomatosis. Treatment is of the underlying
conditions, an important aim being to lower Xeroderma Pigmentosum
the concentrations of fats in the body. A rare disease in which DNA repair mechanisms
Xanthomata have a variety of manifestations fail, rendering the skin especially vulnerable to
which may point to the underlying cause. damage from ultraviolet light (see ULTRAVIOLET
These include: RAYS (UVR)). Extreme photosensitivity begins in
infancy; later, marked freckling occurs and
Eruptive Eruptive yellow papules on the premature CARCINOGENESIS in the skin usually
buttocks. leads to early death. There may also be neuro-
logical complications.
Plane Yellow plaques or macules in the skin.
Xerosis
Abnormal dryness, especially of the eye.
Tuberous Nodules on the elbows or knees.
Xerostomia
Tendinous Subcutaneous nodules fixed to Dryness of the mouth due to lack of SALIVA. Its
tendons, particularly those on the back of the most extreme form occurs following radio-
fingers and the ACHILLES TENDON. therapy of the mouth, and in the condition
known as Sjgrens syndrome. No satisfactory
X Chromosome substitute for natural saliva has been found
One of two SEX CHROMOSOMES. Every normal though some find a methyl-cellulose substitute
female body cell has a pair of X chromosomes. gives partial relief, as may a glycerin mouth-
Men have only one X chromosome and this is wash.
paired with a Y chromosome. The sex cells in
men and women each have one X and one Y Xiphisternum
chromosome. Certain diseases are linked to the See XIPHOID PROCESS.
presence of an X chromosome: these include
HAEMOPHILIA (see GENETIC DISORDERS). (See Xiphoid Cartilage
also GENES.) See XIPHOID PROCESS.
 X-Rays 777

Xiphoid Process iodine-containing contrast agents that ionise in

Also known as the xiphisternum or xiphoid car- solution have been developed for a range of
tilage, this is the small oval-shaped projection other studies.
forming the lowest of the three parts of the More recently a series of improved contrast
STERNUM or breastbone. molecules, chiefly non-ionising, has been
developed, with fewer side-effects. They can,
X-Rays for example, safely be introduced into the spinal
Also known as Rntgen rays, these were dis- theca for myeloradiculography contrast X-
covered in 1895 by Wilhelm Conrad Rntgen. rays of the spinal cord. Using these agents, it is
Their use for diagnostic imaging (radiology) possible to show many organs and structures
and for cancer therapy (see RADIOTHERAPY) is mostly by direct introduction, for example via a
now an integral part of medicine. Many other catheter (see CATHETERS). In urography, how-
forms of diagnostic imaging have been ever, contrast medium injected intravenously is
developed in recent years, sometimes also excreted by the kidneys which are outlined,
loosely called radiology. Similarly the use of together with ureters and bladder. A number of
chemotherapeutic agents in cancer has led to other more specialised contrast agents exist: for
the term oncology which may be applied to the example, for cholecystography radiological
treatment of cancer by both drugs and X-rays. assessment of the gall-bladder. The use of con-
The rays are part of the electro-magnetic trast and the attendant techniques has greatly
spectrum; their wavelengths are between 109 widened the range of radiology.
and 10 13 metres; in behaviour and energy they IMAGE INTENSIFICATION The relative
are identical to the gamma rays emitted by insensitivity of fluorescent materials when used
radioactive isotopes. Diagnostic X-rays are gen- for observation of moving organs for example,
erated in an evacuated tube containing an the oesophagus has been overcome by the use
anode and cathode. Electrons striking the of image intensification. A faint fluorographic
anode cause emission of X-rays of varying image produced by X-rays leads to electron
energy; the energy is largely dependent on the emission from a photo-cathode. By applying a
potential difference (kilovoltage) between high potential difference, the electrons are
anode and cathode. The altered tissue penetra- accelerated across an evacuated tube and are
tion at different kilovoltages is used in radio- focused on to a small fluorescent screen, giving
graphing different regions, for example in a bright image. This is viewed by a TV camera
breast radiography (2540 kV) or chest radi- and the image shown on a monitor and some-
ography (120150 kV). Most diagnostic exam- times recorded on videotape or cine.
inations use kilovoltages between 60 and 120. TOMOGRAPHY X-ray images are two-
The energy of X-rays enables them to pass dimensional representations of three-
through body tissues unless they make contact dimensional objects. Tomography (Greek tomos
with the constituent atoms. Tissue attenuation a slice) began with X-ray imaging produced
varies with atomic structure, so that air- by the linked movement of the X-ray tube and
containing organs such as the lung offer little the cassette pivoting about a selected plane in
attenuation, while material such as bone, with the body: over- and underlying structures are
abundant calcium, will absorb the majority of blurred out, giving a more detailed image of a
incident X-rays. This results in an emerging X- particular plane.
ray pattern which corresponds to the structures In 1975 Godfrey Hounsfield introduced
in the region examined. COMPUTED TOMOGRAPHY (CT). This involves
(i) movement of an X-ray tube around the
Radiography The recording of the resulting patient, with a narrow fan beam of X-rays; (ii)
images is achieved in several ways, mostly the corresponding use of sensitive detectors on
depending on the use of materials which fluor- the opposite side of the patient; (iii) computer
esce in response to X-rays. analysis of the detector readings at each point
CONTRAST X-RAYS Many body organs are not on the rotation, with calculation of relative tis-
shown by simple X-ray studies. This led to the sue attenuation at each point in the cross-
development of contrast materials which make sectional plant. This invention has enormously
particular organs or structures wholly or partly increased the ability to discriminate tissue com- X
opaque to X-rays. Thus, barium-sulphate pre- position, even without the use of contrast.
parations are largely used for examining the gas- The tomographic effect imaging of a par-
trointestinal tract: for example, barium swallow, ticular plane is achieved in many of the newer
barium meal, barium follow-through (or ente- forms of imaging: ULTRASOUND, magnetic res-
roclysis) and barium enema. Water-soluble onance imaging (see MRI) and some forms of
 778 Xylose

nuclear medicine, in particular positron emis- seated conditions, such as cancer of the
sion tomography (PET SCANNING). An alterna- internal organs, much higher voltages are
tive term for the production of images of a required. X-ray machines are now in use
given plane is cross-sectional imaging. which work at two million volts. Even higher
While the production of X-ray and other voltages are now available through the devel-
images has been largely the responsibility of opment of the linear accelerator, which makes
radiographers, the interpretation has been prin- use of the frequency magnetron which is the
cipally carried out by specialist doctors called basis of radar. The linear accelerator receives
radiologists. In addition they, and interested its name from the fact that it accelerates a
clinicians, have developed a number of pro- beam of electrons down a straight tube, 3
cedures, such as arteriography (see ANGI- metres in length, and in this process a voltage
OGRAPHY), which involve manipulative access of eight million is attained. The use of these
for imaging for example, selective coronary or very high voltages has led to the development
renal arteriography. of a highly specialised technique which has
The use of X-rays, ultrasound or computer- been devised for the treatment of cancer and
ised tomography to control the direction and like diseases.
position of needles has made possible guided Protective measures are routinely taken to
biopsies (see BIOPSY) for example, of pan- ensure that the patients normal tissue is not
creatic, pulmonary or bony lesions and thera- damaged during radiotherapy. The operators
peutic procedures such as drainage of too have to take special precautions, including
obstructed kidneys (percutaneous nephros- limits on the time they can work with the
tomy), or of abscesses. From these has grown a equipment in any one period of time.
whole series of therapeutic procedures such as The greatest value of radiotherapy is in the
ANGIOPLASTY, STENT insertion and renal-stone treatment of malignant disease. In many
track formation. This field of interventional patients it can be used for the treatment of
radiology has close affinities with MINIMALLY malignant growths which are not accessible to
INVASIVE SURGERY (MIS). surgery, whilst in others it is used in conjunc-
tion with surgery and chemotherapy.
Radiotherapy, or treatment by
X-rays The two chief sources of the ionising Xylose
radiations used in radiotherapy are the gamma A sugar containing five carbon atoms involved
rays of RADIUM and the penetrating X-rays in the metabolic conversion of carbohydrates
generated by apparatus working at various (see CARBOHYDRATE) inside cells. Xylose is used
voltages. For superficial lesions, energies of in diagnostic tests on the functioning of the
around 40 kilovolts are used; but for deep- INTESTINE.

X
 surveillance can lead to dramatic local

Y recurrences.

Y Chromosome
One of two SEX CHROMOSOMES that is present
in every male body cell where it is paired with
an X CHROMOSOME. The sex or germ cells in
Yawning women as well as men contain one X and one Y
An involuntary opening of the mouth, which is chromosome (see also GENES).
accompanied by marked dilatation of the phar-
ynx, a characteristic distortion of the face and Yeast
usually stretching of the limbs. The cause and This consists of the cells and spores of unicel-
function of yawning are quite obscure. It is lular fungi belonging to the family of Sac-
classically regarded as a sign of drowsiness or charomycetaceae. The main species of yeast used
boredom, but it it may be the result of raised in medicine is Saccharomyces cerevisiae, which is
concentrations of CARBON DIOXIDE (CO2) in used in the fermentation industries, such as
the blood the physiological aim being to cut brewing. It is a rich source of the vitamin B
the amount of CO2 and raise the level of oxygen complex (see APPENDIX 5: VITAMINS), but its use
in the blood. has largely been given up since the various
components of the vitamin B complex became
Yaws available as separate entities.
A non-venereal spirochaetal infection caused by
Treponema pertenue ; it was formerly widespread Yellow Fever
in most tropical and subtropical regions An acute arbovirus (see ARBOVIRUSES) infection
amongst the indigenous population, florid dis- caused by a flavivirus of the togavirus family,
ease being more common in children than transmitted from animals to humans by various
adults. The term is of Carib-Indian (native to species of forest mosquito (jungle/sylvan yellow
north-eastern South America, the east coast of fever), and from human to human by Ades
Central America, and the lesser Antilles) origin. aegypti (urban yellow fever). Mosquito trans-
It is directly contagious from person to person; mission was shown by Walter Reed and his
infection is also transmitted by flies, clothing, colleagues in 1900. It is ENDEMIC in much of
and living in unclean huts. Clinically, the pri- tropical Africa and Central and South America
mary stage is characterised by a granulomatous but does not occur in Asia. In the urban cycle,
lesion, or papule (framboesioma or mother humans constitute the reservoir of infection,
yaw) at the site of infection usually the lower and in the jungle/sylvan variety, mammals
leg or foot; this enlarges, crusts, and heals spon- especially subhuman primates are involved in
taneously. It appears some 28 weeks after transmission. Historically, yellow fever was
infection, during which time fever, malaise, enormously important, causing devastating
pains, and pruritus may be present. In the sec- epidemics (see EPIDEMIC); it also carried a high
ondary stage, a granulomatous, papular, macu- mortality rate in travellers and explorers. Dif-
lar or squamous eruption occurs; periostitis ferentiation from other infections associated
may also be present. The late, or tertiary stage with JAUNDICE was often impossible.
(which appears 510 years later), is character- Clinically, yellow fever is characterised by
ised by skin plaques, nodules, ulcers, hyperk- jaundice, fever, chills, headache, gastrointestinal
eratosis (thickening of the skin of the hands haemorrhage(s), and ALBUMINURIA. The
and feet) and gummatous lesions affecting incubation period is 36 (up to 10) days. Dif-
bones. Recurrence of infection in individuals ferentiation from viral hepatitides, other viral
suffering from a concurrent infection (e.g. haemorrhagic fevers, severe Plasmodium falci-
SYPHILIS or TUBERCULOSIS) renders the infec- parum malaria, and several other infections is
tion more serious. Diagnosis is by demonstra- often impossible without sophisticated investi-
tion of T. pertenue in exudate from a sus- gative techniques. Infection carries a high
pected lesion. Treatment is with PENICILLIN, to mortality rate. Liver histology (biopsy is contra-
which T. pertenue is highly sensitive. Extensive indicated due to the haemorrhagic diathesis)
eradication campaigns (initiated by the WHO shows characteristic changes; a fulminating
in 1949) have been carried out in endemic hepatic infection is often present. Acute
areas; therefore, the early stages of the infec- inflammation of the kidneys and an inflamed,
tion are rarely counted; only tertiary stages congested gastric mucosa, often accompanied
come to the attention of a physician. Failure of by haemorrhage, are also demonstrable;
 780 Yersinia

myocardial involvement often occurs. Diag- discipline involving special breathing tech-
nosis is primarily based on virological tech- niques and a series of prescribed physical poses.
niques; serological tests are also of value. Yellow These are intended to relax the body and teach
fever should be suspected in any travellers from the individual mental and physical control.
an endemic area. Yoga is best learned from experienced teachers,
Management consists of instituting tech- or those practising it may damage their backs.
niques for acute hepatocellular (liver-cell) fail-
ure. The affected individual should be kept in Yoghurt
an isolation unit, away from mosquitoes which Sour milk curdled with one of the LACTIC ACID
could transmit the disease to a healthy indi- producing bacilli, such as Lactobacillus acid-
vidual. Formerly, laboratory infections were ophilus or Lactobacillus bulgaricus. It contains all
occasionally acquired from infected blood sam- the protein, fat, calcium, and vitamins of the
ples. Prophylactically, a satisfactory attenuated original milk, and is therefore a nutritious food,
VACCINE (17D) has been available for around but there is no evidence that it has any unique
60 years; this is given subcutaneously and pro- beneficial properties of its own. In countries
vides an individual with excellent protection for where standards of hygiene are low, it has the
ten years; international certificates are valid for advantage of having been sterilised by boiling
this length of time. Every traveller to an and is therefore unlikely to be contaminated
endemic area should be immunised; this is with dangerous micro-organisms.
mandatory for entry to countries where the
infection is endemic. Yohimbine
This substance is derived from the bark of Paus-
Yersinia inystalia yohimbie, a West African tree. Once
A genus of BACTERIA which includes the causa- widely used as an aphrodisiac an action for
tive organism of PLAGUE, Yersinia pestis. which there is no good evidence, it is now being
used in the treatment of certain cases of pos-
Yin and Yang tural HYPOTENSION and for the treatment of
Basic concepts in traditional Chinese medicine IMPOTENCE.
and philosophy. Yang represents active, positive
masculine qualities. Yin embodies passive, Yttrium-90
negative feminine qualities. An artificially produced ISOTOPE of the element
Yttrium. The isotope is radioactive and emits
Yoga beta rays which are utilised for the treatment of
A system of Hindu philosophy and physical tumours.

Y
 are made up in dusting powders, in ointments,

Z in paste bandages or suspended in water

as lotions for the astringent action they exert
upon abraded surfaces of the skin. Zinc and
castor oil ointment of the British Pharma-
copoeia is a well-tried treatment for nappy
rash.
Zalcitabine Zinc undecenoate is used as an ointment and
A nucleoside REVERSE TRANSCRIPTASE INHIBI- as a dusting-powder in the treatment of
TOR used in the treatment of HIV, in combin- RINGWORM.
ation with other antiretroviral drugs. Serious
side-effects include the risk of peripheral Zollinger-Ellison Syndrome
NEUROPATHY and of pancreatitis (see PANCREAS, A rare disorder in which severe peptic ulcers
DISEASES OF). recur in the stomach and duodenum (see DUO-
DENAL ULCER; STOMACH, DISEASES OF). It is
Zanamivir caused by a tumour in the PANCREAS that pro-
An antiviral drug (trade name Relenza) which duces a hormone, GASTRIN, which stimulates
ameliorates the symptoms of INFLUENZA. It is the stomach and duodenum to produce excess
licensed in the United Kingdom for treating the acid: this causes ulceration. Treatment is by
A or B varieties, 48 hours after the onset of surgery.
symptoms. In otherwise healthy people it
reduces the duration of symptoms by around Zona and Zoster
24 hours. It is not yet known to what extent Two names for the eruption popularly known
zanamivir can prevent complications in high- as shingles. (See HERPES ZOSTER.)
risk patients such as the elderly.
Zonulolysis
Zidovudine The process whereby the zonule (see EYE) is
An antiviral drug used to treat AIDS (see AIDS/ dissolved by an ENZYME (chymotrypsin) as
HIV) and its related conditions, such as pneu- part of intracapsular cataract surgery. Once the
mocystis PNEUMONIA. The drug slows down zonule has been dissolved the cataract can be
the growth of human immunodeficiency virus lifted out of the eye. (See EYE, DISORDERS OF
(HIV) but does not cure the disease. It may be Cataract.)
given intravenously or by mouth. Also called
AZT, zidovudine has been in use since 1987, Zoonoses
and it works by blocking the ENZYME that Animal diseases which can be transmitted to
stimulates HIV to grow and multiply. It may humans. There are more than 150 infections of
cause ANAEMIA so regular blood tests are domestic and wild vertebrates which can be
necessary. transmitted in this way, including BOVINE
SPONGIFORM ENCEPHALOPATHY (BSE), bovine
Zinc tuberculosis, BRUCELLOSIS, HYDATID cysts,
A metal, several salts of which are used in medi- RINGWORM, TOXOCARIASIS, TOXOPLASMOSIS,
cine for external application. It is essential for LEPTOSPIROSIS, LISTERIOSIS, and RABIES.
growth and development in animals and plants.
The average human body contains a total of 1 Zygoma
2 grams, and most human diets contain 1015 Or zygomatic bone. The name given to a
mg. In human beings, deficiency of zinc results bridge of bone formed by the union of a pro-
in lack of growth, slow sexual development cess from the temporal bone in the skull with
and ANAEMIA. Deficiency is also associated with one from the malar (cheek) bone. It lies in the
a skin disorder known as acrodermatitis region of the temple, gives attachment to the
enteropathica. powerful masseter muscle which moves the
lower jaw, and forms a protection to the side of
Uses Zinc chloride is a powerful caustic and the head.
astringent which, combined with zinc sulphate,
is used as an astringent mouthwash. Zinc sul- Zygote
phate is also used in the form of eyedrops in the This is the cell produced when an OVUM is fer-
treatment of certain forms of conjunctivitis (see tilised by a SPERMATOZOON. A zygote contains
under EYE, DISORDERS OF). all the hereditary material for a new individual:
Zinc oxide, zinc stearate, and zinc carbonate half comes from the sperm and half from the
 782 Zymolysis

Fertilisation of the female ovum by the male sperm cell to form the zygote.

ovum. After passing down the Fallopian tube, Zymolysis

when the zygote starts dividing, it becomes The mechanism of fermentation initiated by an
implanted in the UTERUS and develops into an ENZYME during DIGESTION.
EMBRYO.

Z
APPENDIX 1: BASIC FIRST AID

This appendix is designed to cover the basic dry heat, severe cold, corrosive materials, radi-
principles involved in the immediate treatment ation (including rays from the sun) and friction
of some common emergencies. It is not com- (such as results from a body sliding along a road
prehensive, and anyone wishing to become surface after a motorcycle accident). Scalds are
proficient at first aid should attend a course run caused by hot fluids or steam. Burns and scalds
by a reputable organisation such as the British may be associated with other injuries caused,
Red Cross, St John Ambulance, and the St say, by an escape from a burning building, a
Andrews Ambulance Association. A knowledge road traffic accident or an explosion: casualties
of first aid can be of great practical value should therefore be examined for other injuries.
whether at home, at work or when travelling. Most burns and scalds affect the skin, and the
On occasions its prompt application may save area(s) and site(s) of skin damaged are import-
someones life or lessen the potential harm of an ant in assessing a victims condition. Muscles
accident. and other tissues may be damaged by burns,
First-aid treatment in an emergency is and inhalation of smoke or fumes may damage
intended: the linings of the mouth, throat and lungs.
to preserve life and stop the victims condi-
tion from deteriorating.
Shock, sometimes severe, is common the
result of pain and loss of body fluids. All but the
to help recovery and save the victim from most minor burns should be seen by a doctor, as
further harm. it is difficult to assess the severity of the burn
to make the casualty as comfortable as pos-
sible and reassure him/her and the family.
immediately after it occurs. If the person or his
or her clothing is actually on fire, then the first
to assess the events surrounding the illness or move must be to smother the flames by cover-
accident so that relevant facts can be given to ing them with a blanket or coat, for example
a doctor, nurse or paramedical staff. and patting out the flames without sustaining
No ill or badly injured person should be burns yourself. Many burns, however, are
moved without skilled assistance especially if caused by hot liquids, hot gases, flashes from
a neck or spinal injury is suspected unless the explosions or contact with a very hot object so
individuals life is in immediate danger from that the person is not actually on fire. The
the surroundings (e.g. a fire). He or she should treatment for all these burns is the same to
be kept warm; constricting clothing should be remove any clothing over the affected area, if
loosened; and a clear airway should be estab- possible, and to put the affected area under cold
lished, with any false teeth removed. running water until the pain has stopped or the
ambulance has arrived (the cold water should
Bleeding This may occur from arteries, veins be applied for several minutes, as cooling of the
or capillary beds. The former is easily recog- tissues, particularly the deeper layers of the skin,
nised as the blood tends to spurt from the will limit the extent of the burn). The burn
wound at the same rate as the pulse; with the should be left exposed or covered with a piece of
latter two types the blood tends to flow from clean wet linen (e.g. a pillowcase), for the trans-
the wound. Minor bleeding is usually treated in fer to hospital. No lotions or potions should be
the home by the application of bandages, etc. applied to the burn until it has been seen by a
However, the basic principles of treatment for doctor or a nurse. (See also main dictionary entry
major haemorrhages may be applied. Pressure for BURNS AND SCALDS.)
should be applied to the bleeding point, via
gauze or a clean piece of cloth if available, Choking Severe life-threatening CHOKING
firmly enough to stop the flow of blood. With occurs when a piece of food or a foreign object
the pressure applied, the wound should be becomes lodged in the LARYNX or TRACHEA
raised above the level of the heart. The patient causing obstruction. The person may cough,
should then be transferred to a place where gag, or wheeze and will become cyanosed (blue)
medical care is available. If the loss of blood is as he or she fights to take a breath. Infants or
severe enough for the victim to have become small children should be held along the arm,
shocked (see SHOCK), he or she should be laid head down, and several gentle blows with the
flat with the legs raised, if possible. (See also flat of the hand should be delivered to the back
HAEMORRHAGE.) between the shoulder-blades: this will usually
dislodge the foreign body. In older children or
Burns and scalds Burns can be caused by adults the Heimlich manoeuvre should be
784 Appendix 1: Basic First Aid

employed. Stand behind the victim with your the nose and steady the head, and the other to
arms wrapped around the waist. Make a fist pull the jaw forwards and open the mouth. The
with one hand, with the thumb placed at a rescuer then places his or her mouth completely
point half-way between the victims navel and over that of the victim and blows out so as to
the bottom of the breastbone. Grasp the fist inflate the victims lungs, starting with two slow
with your other hand and give a quick inward breaths to reinflate the lungs. It is important to
and upward thrust. This may be repeated sev- observe the victims chest rise and fall normally
eral times if necessary. Alternatively, if the per- before commencing the next breath. If the chest
son is unconscious, he or she should be placed does not rise, or if there is marked resistance to
on the back, face up, and the same thrust per- the inflating breath, then the airway is probably
formed with the heel of the hand whilst kneel- obstructed and the head should be
ing astride the hips. If a choking person is repositioned.
alone, he or she can perform the manoeuvre by CIRCULATION Ventilating the lungs without
placing a fist in the correct position and deliver- any blood circulating will not provide oxygen-
ing the thrust by pressing it against a firm ated blood to vital organs. Therefore, if there is
surface. no pulse or heartbeat, cardiac massage should
be started to produce this circulation. The per-
Cardiac/respiratory arrest The meas- son performing cardiac massage who should
ures described here are basic life-support pro- preferably have been trained in the technique
cedures they can be performed if necessary should kneel beside the victim with the heel of
without any equipment. Before commencing one hand over the lower two-thirds of the
cardiopulmonary resuscitation on a person who breastbone and the other hand placed on top.
has collapsed, it is essential to establish that it is Downward pressure is applied, keeping the
in fact required. Performing artificial ventila- arms straight with the elbows locked, so as to
tion and cardiac massage on a person who is depress the breastbone 45 cm. Pressure is
breathing and whose heart is still beating can be released slowly so that it takes the same time as
dangerous. The persons chest and abdomen compression. The rate of compressions should
should be observed for respiratory movement be 80 per minute. If there are two rescuers, then
and the PULSE should be checked either at the the person performing cardiac massage should
neck or groin or by feeling directly over the stop after every five compressions to allow the
heart. other to perform one cycle of artificial ventila-
The technique for simple resuscitation may tion. A lone rescuer should perform two breaths
be remembered by means of the mnemonic after every 15 compressions.
ABC (Airway, Breathing and Circulation). Once spontaneous ventilation and cardiac
The aim of basic resuscitation is to maintain the output have returned, the patient should be
flow of oxygenated blood to vital organs until placed in the recovery, or coma, position. This
the persons heartbeat and breathing can be consists of rolling the person on to his or her
restarted, if that is possible. side, with the lower arm and leg straight and in
AIRWAY If the airway is obstructed, no air can line with the body. The upper arm and leg are
enter the lungs; therefore the mouth should be flexed and brought forwards to prevent the
checked for foreign bodies, which can be patient from rolling on to his or her front.
removed by hooking them out with an index
finger. False teeth should be removed. To pre- Drowning Around 500 people die from
vent the tongue from obstructing breathing, the drowning each year in Britain, and an unknown
jaw should be pulled forwards (using a finger number survive a near-drowning. About one-
behind the angle of the chin) and the head fifth of drownings occur in salt water. Wet
extended on the neck so that the person looks as drowning (when water is aspirated into the
if he or she is sniffing the morning air. lungs) occurs in 85 per cent of cases; the
Care must be taken if there is any suspicion remaining 15 per cent develop laryngospasm
of neck injury. so that, although they also die of ASPHYXIA, no
BREATHING If clearing the airway does not water enters the lungs.
allow breathing to recommence, then artificial There has been some controversy about what
ventilation of the lungs must be started. type of water carries the worst prognosis, but it
Mouth-to-mouth ventilation, using the res- is now thought that salt and fresh water are
cuers expired air to inflate the victims lungs, is equally bad. The effect of salt water is to draw
probably the easiest and most satisfactory tech- fluid into the alveoli (see ALVEOLUS) from the
nique. The victim is positioned as described vascular compartment with concomitant dam-
above. The rescuer uses one hand to obstruct age to the lung. This results in PULMONARY
 Appendix 1: Basic First Aid 785

OEDEMA and HYPOXIA. Fresh water washes out Foreign bodies Unwanted objects may
pulmonary SURFACTANT (causing pulmonary enter the eyes, ears, nose, mouth and gullet
atelectasis and leading to hypoxia) and is (OESOPHAGUS), the lungs and wounds. Foreign
absorbed into the vascular compartment caus- bodies in wounds, the lungs, mouth, gullet and
ing volume overload and electrolyte disturb- stomach should be treated by a doctor or nurse;
ances. Both types may result in ACIDOSIS and unskilled attempts to remove them may harm
circulatory collapse, and may be complicated by the patient.
HYPOTHERMIA and trauma (which may indeed EYES Dust, eyelashes and displaced contact
have precipitated the drowning). lenses that have not penetrated the tissue of the
eye are usually easily removed by washing with
Treatment Cardiopulmonary resuscitation clean water, preferably using an eyebath. If the
(see cardiac/respiratory arrest in this appendix) foreign body is stuck to or has penetrated the
should be started as soon as possible and the surface of the eye, the eye should be covered
patient transferred to hospital. This should with a clean pad and medical attention
include people who recover consciousness fairly obtained.
quickly, as pulmonary oedema may develop EARS AND NOSE Do not attempt to remove
over the next few hours. If the patient is hypo- the foreign body: obtain medical attention.
thermic (see HYPOTHERMIA), resuscitation
should continue until he or she has been Heatstroke This occurs when the body
warmed to normal body temperature. Patients becomes dangerously overheated because of a
may require admission to an intensive care high fever or prolonged exposure to heat for
unit for artificial ventilation, circulatory sup- example, being out in the hot sun or working in
port, or correction of electrolyte imbalance or a hot environment (e.g. near a furnace). Heat-
acidosis. stroke may suddenly occur or manifest itself by
the victims feeling uncomfortable, ill or con-
Electrocution People may be electrocuted fused. Remove the casualty from the heat
when they touch an object which is live so that source and lower the body TEMPERATURE by
a current passes through them to earth. A light- removing clothing and wrapping the patient in
ning strike has a similar effect. The severity of a cold wet sheet or towel, fanning him or her
the outcome depends upon the frequency and and sponging with cold water. Obtain urgent
amplitude of the current which flows through medical attention.
them. Below 2mA there is only a feeling of
strong PARAESTHESIA; 15100mA will produce Inhalation of fumes The inhalation of
muscular contraction in the muscles near the gases, smoke or toxic vapours can rapidly cause
point of contact, which makes letting go of the death. Victims need to be removed quickly
object impossible; and 50mA2A is the thresh- from the source of the fumes, but the rescuer(s)
old for producing VENTRICULAR FIBRILLATION. may need protective equipment in order to do
(These thresholds are for the mains electricity this. Attempts by inexperienced, unprotected
supply, which in Britain has a frequency of persons may well result in further casualties, so
50Hz one that is particularly liable to induce emergency services should be called promptly.
ventricular fibrillation.) Thus electrocution can CARBON MONOXIDE (CO) is particularly dan-
cause burns (see burns and scalds, above) to the gerous because it has neither taste nor smell and
tissues at the sites where the current enters and can speedly overcome anyone exposed to the
leaves the body, and may also induce ventricular gas, especially in a confined space such as kit-
fibrillation. If a person is seen being electro- chen or garage. Victims need to be taken into
cuted, no attempt should be made to touch the the open air and their breathing quickly
victim until the power supply is turned off, as restored with artificial respiration (see cardiac/
the helper may also be electrocuted. If the respiratory arrest, above) and oxygen, if avail-
switch or mains supply cannot be found, then able. (Remember that oxygen is very inflam-
the victim should be knocked away from the mable and is normally given by skilled staff
power source using a non-conducting object using appropriate equipment.)
such as wood. Burns should be treated as
described above and, if the patient has Poisoning The number of substances with
developed ventricular fibrillation, then cardio- which people are poisoned, either deliberately
pulmonary resuscitation should be started (see or accidentally, is too great to list individually.
cardiac/respiratory arrest in this appendix). Any This section will merely cover some basic prin-
person experiencing significant electrocution ciples to follow on discovering a person who has
should be seen by a doctor. been poisoned.
786 Appendix 1: Basic First Aid

If the person is unconscious, he or she should when he or she shakes. At the end of the fit
be nursed in the coma position (see cardiac/ there is usually a period of unconsciousness.
respiratory arrest in this appendix). Vomiting The most important task in looking after
should never be induced at home except under people undergoing a fit is to prevent them from
medical supervision. If corrosive substances doing any damage to themselves. Any objects
have been ingested, then water or milk should which might cause harm, particularly hot food
be drunk to dilute the effects on the oesophagus and liquids, should be moved out of their way,
and stomach, and any remaining on the skin but there is no need to try to move the person
should be washed away with copious volumes themselves unless they are in danger (it may,
of water. The container from which the tablets however, be necessary to roll them on to their
or other substance came should be taken to side to prevent asphyxiation). No attempt
hospital with the patient to help medical staff should be made to protect the tongue, and a
correctly identify the poison. Likewise if it is a finger should not be inserted in the mouth to
plant, a leaf or a berry. (See also POISONS.) straighten the tongue. Clothing around the
patients neck should be loosened and, if pos-
Seizures A major SEIZURE or fit is known as sible, a pillow placed under the neck. At the
a Grand Mal convulsion (see EPILEPSY) and con- end of the fit, when the person is unconscious,
sists of two phases: the tonic phase when the he or she should be placed in the coma or
person may let out a cry, falls to the ground and recovery position (see cardiac/respiratory arrest,
is observed to be rigid; and the clonic phase above).
APPENDIX 2: ADDRESSES: SOURCES OF INFORMATION, ADVICE,
SUPPORT AND SELF-HELP
Addresses for other information and support groups can be found in the Voluntary Agencies Directory
(published by NCVO Publications, National Council for Voluntary Organisations, Regents Wharf,
8 All Saints Street, London N1 9RL [020 7713 6161, distribution: 01536 399016]). Telephone
helpline numbers can be found in the Telephone Helplines Directory (published by the Telephone
Helplines Association, 4th Floor, 9 Marshalsea Road, Borough, London SE1 1EP 020 7089 6321,
fax: 020 7089 6320, website: www.helplines.org.uk]) and in the helpline sections of Thomson Local
telephone directories. Information on many rare disorders may be found in The CaF Directory (see
children, below). Helpline numbers beginning 0800 and 0808 are free; 0845 calls are charged at
local rates; and 0870 calls at national rates.

ACCIDENT PREVENTION IN THE Alcoholics Anonymous, PO Box 1, Stonebow

HOME Child Accident Prevention Trust, 4th House, Stonebow, York YO1 7NJ (01904
floor, 1820 Farringdon Lane, London EC1R 644026, helpline: 0845 769 7555, fax:
3HA (020 7608 3828, fax: 020 7608 3674, 01904 629091, website: www.alcoholics-
e-mail: [email protected]). anonymous.org.uk).

Royal Society for the Prevention of Accidents, Al-Anon Family Groups UK and Eire (includ-
Edgbaston Park, 353 Bristol Road, Birming- ing Alateen), 61 Great Dover Street, London
ham B5 7ST (0121 248 2000, fax: 0121 248 SE1 4YF (helpline: 020 7403 0888, fax: 020
2001, website: www.rospa.com, e-mail: help@ 7378 9910, website: www.al-anonuk.org.uk).
rospa.com).
Alcohol Concern, Waterbridge House, 3236
ADOPTION See child adoption. Loman Street, London SE1 0EE (020
7928 7377, fax: 020 7928 4644, website:
AGEING Age Concern England, Astral www.alcoholconcern.org.uk, e-mail: contact@
House, 1268 London Road, Norbury, London alcoholconcern.org.uk).
SW16 4ER (020 8765 7200, helpline: 0800 00
99 66 (7 days, 07001900), fax: 020 8765
Alcohol Focus Scotland, 2nd Floor, 166
7211, website: www.ageconcern.org.uk, e-mail:
Buchanan Street, Glasgow G1 2LW (0141
ace@ ace.org.uk).
572 6700, fax: 0141 333 1606, website:
www.alcohol-focus-scotland.org.uk, e-mail:
Help the Aged, 207221 Pentonville Road, [email protected]).
London N1 9UZ (020 7278 1114, fax: 020
7278 1116, website: www.ageconcern.org.uk,
e-mail: [email protected]). ALZHEIMERS DISEASE Alzheimers Soci-
ety, 2nd Floor, Gordon House, 10 Greencoat
Place, London SW1P 1PH (020 7306 0606,
AGORAPHOBIA See phobias.
helpline: 0845 300 0336, fax: 020 7308 0808,
website: www.alzheimers.org.uk, e-mail:
AIDS Terrence Higgins Trust Lighthouse enquiries@ alzheimers.org.uk).
(THTL), 5254 Grays Inn Road, London
WC1X 8JU (020 7831 0330, helpline: 0845
1221 200 [MF, 10002200, SS, 1200 ANKYLOSING SPONDYLITIS The
1800], fax: 020 7242 0121, website: www. National Ankylosing Spondylitis Society
tht.org.uk, e-mail: info@ tht.org.uk). (NASS), PO Box 179, Mayfield, East Sussex
TN20 6ZL (01435 873527, fax: 01435
Communicable Diseases Surveillance Centre: 873027, website: www.nass.co.uk, e-mail:
see public health laboratory services, appendix [email protected]).
7: statutory organisations.
ANOREXIA See eating disorders.
ALCOHOL ACCEPT: Alcohol and Substance
Misuse, 724 Fulham Road, London SW6 5SE ARTHRITIS Arthritis Care, 18 Stephenson
(administration: 020 7371 7555, clients: 020 Way, London NW1 2HD (020 7380 6500,
7371 7477). helpline: 0808 800 4050 [MF, 12001600],
788 Appendix 2: Addresses

or 020 7380 6555 (10001600), fax: 020 7380 BREAST FEEDING National Childbirth
6505, website: www. arthritiscare.org.uk). Trust (see childbirth), Alexandra House, Old-
ham Terrace, London, W3 6NH (0870 4448
ASTHMA Asthma UK, Providence House, 707, breastfeeding line: 0870 4448 708).
Providence Place, London N1 0NT (020 7226
2260, helpline: 0845 701 0203, fax: 020 7704 La Leche League of Great Britain (LLLGB), PO
0740, website: www.asthma.org.uk). Box 29, West Bridgford, Nottingham, NG2
7NP (helpline 0845 120 2918 [24 hours],
ATAXIA UK Room 10, Winchester House, website: www.laleche.org.uk).
Kennington Park, 11 Cranmer Road, London
SW9 6EJ (020 7582 1444, helpline: 0845 644 BRITTLE BONE DISEASE Brittle Bone Soci-
0606, fax: 020 7582 9444, website: ataxia. ety, 30 Guthrie Street, Dundee DD1 5BS
org.uk, e-mail: [email protected]). (01382 204446, helpline: 0800 028 2459, fax:
01382 206771, website: www.brittlebone.org,
AUTISM The National Autistic Society, 393 e-mail: [email protected]).
City Road, London EC1V 1NG (020 7833
2299, helpline: 0845 070 4004 [MF, 1000- CANCER CARE Macmillan Cancer Relief, 89
1600], fax: 020 7833 9666, website: Albert Embankment, London SE1 7UQ (020
www.nas.org.uk, e-mail: [email protected]). 7840 7840, helpline: 0808 808 2020, fax: 020
7840 7841, website: macmillan.org.uk).
BACK PAIN Back Care, 16 Elmtree Road,
Teddington, Middlesex TW11 8ST (020 Marie Curie Cancer Care, 89 Albert Embank-
8977 5474, fax: 020 8943 5318, website: ment, London SE1 7TP (020 7599 7777, fax:
www.backcare.org.uk, e-mail: website@ 020 7599 7785, website: www. mariecurie.
backcare.org.uk). org.uk, e-mail: [email protected]).
BLINDNESS Royal National Institute for the
Blind (RNIB), 105 Judd Street, London CANCER INFORMATION SERVICE Cancer
WC1H 9NE (020 7388 1266, helpline: BACUP, 3 Bath Place, Rivington Street, Lon-
0845 766 9999, fax: 020 7388 2034, don EC2A 3DR (020 7696 9003, helpline:
website: www.rnib.org.uk, e-mail: helpline@ 0808 800 1234 or 0207 739 2280 standard rate
rnib.org.uk). [MF 09001900], fax: 020 7696 9002, web-
site: www.cancerbacup.org.uk).
BLOOD TRANSFUSION National Blood
Service, Oak House, Reeds Crescent, Watford, CARERS Carers National Association, 2025
Herts. WD24 4QN, (0845 7 711 711, website: Glasshouse Yard, London EC1A 4JT (020
www.blood.co.uk). The authority is responsible 7490 8818, helpline: 0845 573 369, fax: 020
for 15 regional centres in England. 7490 8824, e-mail: [email protected], website:
www. carersuk.org.
BRAIN INJURIES Headway the brain injury
association, 4 King Edward Court, King Womens Royal Voluntary Service, Garden
Edward Street, Nottingham NG1 1EW (0115 House, Milton Hill, Steventon, Oxfordshire
924 0800, textphone: 0115 950 7825, fax: OX13 6AD (01235 442900, fax: 01235
0115 958 4446, website: www.headway.org.uk, 861166, website: www.wrvs.org.uk).
e-mail: [email protected]).
CARE SERVICES Counsel and Care, Twyman
BREAST CANCER CARE Breast Cancer House, 16 Bonny Street, London NW1 9PG
Care, Kiln House, 210 New Kings Road, (020 7241 8555, helpline: 0845 300 7585
London SW6 4NZ (020 7384 2984, helpline: [MF 10001300], fax: 020 7267 6877,
0808 800 6000, textphone: 0808 800 6001, fax: website: www.counselandcare.org.uk, e-mail:
020 7384 3387, website: www.breastcancercare. [email protected]).
org.uk, e-mail: [email protected]).
CEREBRAL PALSY SCOPE, PO Box 833,
Scottish office: 4th Floor, 40 St Enoch Milton Keynes MK12 5NY (020 7619 7100,
Square, Glasgow, G1 4DH, (0845 0771 helpline: 0808 800 3333 [MF, 09002100,
892, fax: 0141 221 9499, e-mail: SS, 14001800], fax: 020 7619 7399, website:
[email protected]). www.scope.org.uk).
 Appendix 2: Addresses 789

Advice Service Capability Service Scotland National Society for the Prevention of Cruelty
(ASCS), 11 Ellersly Road, Edinburgh EH12 to Children (NSPCC), Weston House, 42
6HY (0131 313 5510, textphone: 0131 346 Curtain Road, London EC2A 3NH (020 7825
2529, fax: 0131 346 1681, website: 2500, helpline: 0808 800 5000, fax: 020 7825
www.capability-scotland.org.uk, e-mail: ascs@ 2525, website: nspcc.org.uk).
capability-scotland.org.uk).
NCH Action for Children, 85 Highbury Park,
CHILD ADOPTION Adoption UK, 46 The London N5 1UD (020 7704 7000, helpline:
Green, South Bar Street, Banbury OX16 0845 762 6579, fax: 020 7226 2537, website:
9AB (helpline: 0870 7700 450, tel: 01295 nch.org.uk).
752240, fax: 01295 752241, website:
www.adoptionuk.org.uk, e-mail: helpdesk@ CHIROPODY See appendix 8: professional
adoptionuk.org.uk). organisations.

Adoptions Section, Office for National Stat- CLEFT LIP AND PALATE See palate
istics, Smedley Hydro, Trafalgar Road, malformations.
Birkdale, Southport PR8 2HH (0151 471
4313, fax: 0151 471 4755). COCHRANE COLLABORATION Update
Software Ltd, Oxford OX2 7LG (01865
British Agencies for Adoption and Fostering 513902, website: www.cochrane.co.uk, e-mail:
(BAAF), Skyline House, 200 Union Street, [email protected]).
London SE1 0LX (020 7593 2000, fax: 020
7593 2001, website: www.baaf.org.uk, e-mail: COELIAC DISEASE Coeliac Society of the
[email protected]). United Kingdom, PO Box 220, High
Wycombe, Buckinghamshire HP11 2HY
National Organisation for Counselling Adopt- (01494 437278, helpline 0870 444 8804, fax:
ees and Parents (NORCAP), 112 Church 01494 474349, website: www.coeliac.co.uk,
Road, Wheatley, Oxfordshire OX33 1LU e-mail: helpline@ coeliac.co.uk).
(01865 875000 [MTh 10001600], fax:
01865 875686, website: www.norcap.org.uk, COLITIS AND CROHNS DISEASE
e-mail: [email protected]). National Association for Colitis and Crohns
Disease, 4 Beaumont House, Sutton Road, St
CHILDBIRTH National Childbirth Trust, Albans, Hertfordshire AL1 5HH (01727
Alexandra House, Oldham Terrace, Acton, 830038, helpline: 0845 130 2233, fax: 01727
London W3 6NH (enquiries: 0870 444 8707, 862550, website: www.nacc.org.uk, e-mail:
breastfeeding line: 0870 444 8708, fax: 0870 [email protected]).
770 3237, website: www.nctpregnancyandbaby
care.com), e-mail: enquiries@national- COLOSTOMY British Colostomy Associ-
childbirth-trust.co.uk). ation, 15 Station Road, Reading, Berkshire
RG1 1LG (0118 939 1537, helpline: 0800 328
CHILDREN Action for Sick Children, 4257, fax: 0118 956 9095, website: www.bcass.
National Childrens Bureau, 8 Wakley Street, org.uk, e-mail: [email protected]).
London EC1V 7QE, (020 7843 6444, website:
www. actionforsickchildren.org, e-mail: enquir- CORONARY HEART DISEASE Coronary
ies@ actionforsickchildren.org). Prevention Group, 2 Taviton Street, London
WC1H 0BT (020 7927 2125, fax: 020 7927
Contact a Family, 209211 City Road, London 2127, website: www.healthnet.org.uk, e-mail:
EC1V 1JN (020 7608 8700, helpline: 0808 [email protected]).
808 3555 [MF, 10001600], fax: 020 7608
8701, website: www.cafamily.org.uk, e-mail: CYSTIC FIBROSIS Cystic Fibrosis Trust, 11
[email protected]). A charity which pro- London Road, Bromley, Kent BR1 1BY (020
vides families who care for children with any 8464 7211, fax: 020 8313 0472, website:
disability or special need with authoritative, www.cftrust.org.uk, e-mail: enquiries@
accessible, descriptive information. It is a main cftrust.org.uk).
source of information about rare disorders and
helps adults as well as children. The CaF Direc- DEAFNESS Royal National Institute for Deaf
tory lists established UK support organisations People, 1923 Featherstone Street, London
and is available on the charitys website: EC1Y 8SL (020 7296 8000, info: 0808
www.cafamily.org.uk/dirworks.html. 808 0123, 0808 808 9000 (text), fax: 020 7296
790 Appendix 2: Addresses

8199, website: www.rnid.org.uk, e-mail: 0212, website: www.radar.org.uk, e-mail:

[email protected]). [email protected]).

Defeating Deafness (Hearing Research Shaftesbury Society, 16 Kingston Road, Lon-

Trust), 330332 Grays Inn Road, London don SW19 1JZ (0845 330 6033, fax: 020 8239
WC1X 8EE (020 7833 1733, fax: 020 5580, website: www.shaftesburysoc.org.uk,
7278 0404, website: www.defeatingdeafness. e-mail: [email protected]).
org, e-mail: [email protected]).
DONORS BODY: British Organ Donor Soci-
National Deaf Childrens Society, 15 Dufferin ety, Balsham, Cambridge CB1 6DL (telephone
Street, London EC1Y 8UR (020 7490 8656, and fax: 01223 893636, website: www. argon-
helpline: 0808 800 8880 [both voice and text], et.co.uk/body, e-mail: [email protected]).
fax: 020 7251 5020, website: www.ndcs.
org.uk, e-mail: [email protected]). HM Inspector of Anatomy, Department of
Health, Wellington House, 133155 Waterloo
Sense, 1113 Clifton Terrace, Finsbury Park, Road, London SE1 8UG (020 7972 4342,
London N4 3RS (020 7272 7774, fax: 020 fax: 020 7972 4791, e-mail: karen.huscroft@
7272 6012, website: www.sense.org.uk, e-mail: doh.qsi.gov.uk).
[email protected]).
National Blood Service: 0845 7 711 711.
Sense Scotland, 43 Middlesex Street, Kinning
Park, Glasgow G41 1EE (0141 429 0294,
NHS Organ Donor Register, FREEPOST
0141 418 7170 (text), fax: 0141 429 0295,
(SWB1474), Patchway, Bristol BS34 8ZZ,
website: www.sensescotland.org.uk, e-mail:
0845 60 60 400.
[email protected]).
DOWNS SYNDROME Downs Syndrome
DERMATITIS National Eczema Society, Hill
Association, Langdon Down Centre, 2a
House, Highgate Hill, London N19 5 NA (020
Langdon Park, Teddington TW11 9PS
7281 3553, helpline: 0870 241 3604, fax: 020
(0845 230 0372, fax: 0845 230 0373,
7281 6395, website: www.eczema.org).
website: www.downs-syndrome.org.uk, e-mail:
[email protected]).
DIABETES Diabetes UK, 10 Parkway, Lon-
don NW1 7AA (0207 424 1000, helpline:
0845 120 2960, fax: 0207 424 1001, website: DRUG DEPENDENCE National Drugs
www.diabetes.org.uk, e-mail: info@diabetes. Helpline: 0800 776600, website: www.
org.uk). talktofrank.com.

DISABLED LIVING British Red Cross, DYSLEXIA British Dyslexia Association, 98

British Red Cross UK Office, 44 Moorfields, London Road, Reading, Berkshire RG1 5AU
London, EC2Y 9AL (0870 170 7000, fax: (0118 966 2677, fax: 0118 935 1927, helpline:
020 7562 2000, website: www.redcross.org.uk, 0118 966 8271, website: www.bda-dyslexia.
e-mail: information@ redcross.org.uk). org.uk, e-mail: [email protected]).

Disabled Living Foundation, 380384 Harrow DYSPHASIA Speakability, 1 Royal Street,

Road, London W9 2HU (020 7289 6111, London SE1 7LL (020 7261 9572, fax: 020
helpline: 0845 130 9177, textphone: 020 7432 7928 9542, helpline: 080 8808 9572,
8009, fax: 020 7266 2922, website: website: www.speakability.org.uk, e-mail:
www.dlf.org.uk, e-mail: [email protected]). [email protected]).

Motability Operations, City Gate House, The Stroke Association, 240 City Road, London
22 Southwark Bridge Rd, London SE1 9HB EC1V 2PR (0845 3033 100, fax: 020 7490
(0845 456 4566, fax: 020 7928 1818, website: 2686, website: www.info.org.uk, e-mail:
www.motability.co.uk). info@ stroke.org.uk).

Royal Association for Disability and Rehabilita- DYSTONIA Dystonia Society, 4647 Britton
tion (RADAR), 12 City Forum, 250 City Street, London EC1M 5UJ (020 7490 5671,
Road, London EC1V 8AF (020 7250 3222, fax: 020 7490 5672, website: www.dystonia.
textphone: 020 7250 4119, fax: 020 7250 org.uk, e-mail: [email protected]).
 Appendix 2: Addresses 791

EATING DISORDERS Eating Disorders HEAD INJURIES See brain injuries.

Association, 1st Floor, Wensum House, 103
Prince of Wales Road, Norwich NR1 1DW HEARING AIDS See deafness.
(01603 619090, helpline: 0870 770 3256,
textphone: 01603 753322, fax: 01603 HOSPITAL FRIENDS National Assocation
664915, website: www.edauk.com, e-mail: of Hospital and Community Friends, 1113
[email protected]). Cavendish Square, London W1G 0AN (0845
450 0285, website: www.hc-friends.org.uk,
ECLAMPSIA AND PRE-ECLAMPSIA e-mail: [email protected]).
Action on Pre-Eclampsia (APEC), 8488 Pin-
ner Road, Harrow, Middlesex HA1 4HZ (020 HUNTINGTONS CHOREA Huntingtons
8863 3271, helpline: 020 8427 4217 [MF, Disease Association, 108 Battersea High Street,
10001300, recorded advice at other times], London SW11 3HP (020 7223 7000, fax: 020
fax: 020 8424 0653, website: www.apec.org.uk, 7223 9489, website: www.hda.org.uk, e-mail:
e-mail: enquiries@ apec.org.uk). [email protected]).
ECZEMA See dermatitis. ILEITIS See colitis and crohns disease.
EPILEPSY British Epilepsy Association, New
ILEOSTOMY The Ileostomy and Internal
Anstey House, Gate Way Drive, Yeadon, Leeds
Pouch Support Group (ia), Peverill House,
LS19 7XY (0113 210 8000, fax: 0113 391
15 Mill Road, Ballyclare, Co. Antrim
0300, website: www.epilepsy.org.uk, e-mail:
BT 39 9DR (0800 0184 724, 028 9334 4043,
[email protected]).
fax: 028 9332 4606, [email protected],
website: www.the-ia.org.uk).
Epilepsy Action Scotland, 48 Govan Road,
Glasgow G51 1JL (0141 427 4911, help-
line: 0808 800 2200, fax: 0141 419 1709, LARYNGECTOMY The National Associ-
website: www.epilepsyscotland.org.uk, e-mail: ation of Laryngectomee Clubs, Ground Floor, 6
[email protected]). Rickett Street, Fulham, London SW6 1RU
(020 7381 9993, fax: 020 7381 0025).
FAMILY PLANNING fpa, 212 Pentonville
Road, London N1 9FP (020 7837 5432, help- LEARNING DISABILITY British Institute
line: 0845 310 1334, fax: 020 7837 3042, of Learning Disabilities, Green Street, Kid-
website: www.fpa.org.uk). derminster, Worcestershire DY10 1JL (01562
723010, fax: 01562 723029, website:
FERTILITY Infertility Network UK, Charter www.bild.org.uk).
House, 43 St Leonards Road, Bexhill on Sea,
East Sussex TN40 1JA (08701 188 088, web- ENABLE (Scottish Society for the Mentally
site: www.infertilitynetworkuk.com). Handicapped), 7 Buchanan Street, Glasgow
G1 3HL (0141 226 4541, fax: 0141 204
FIRST AID British Red Cross, 44 Moorfields, 4398, website: www.enable.org.uk: e-mail:
London EC2Y 9AL (0870 170 7000, fax: [email protected]).
0207 562 2000, website: www.redcross.org.uk,
e-mail: [email protected]). MENCAP (Royal Society for Mentally Handi-
capped Children and Adults), 123 Golden
St Andrews Ambulance Association, Strachan Lane, London EC1Y 0RT (020 7454
House, 16 Torphichen Street, Edinburgh EH3 0454, fax: 020 7696 5540, website:
8JB (0131 229 5419, fax: 0131 228 2424). www.mencap.co.uk, e-mail: information@
mencap.org.uk).
St John Ambulance, 27 St Johns Lane, Clerk-
enwell, London EC1M 4DA (0870 10 49 50, Mental Health Foundation, 20 Upper Ground,
fax: 0870 10 40 65, website: www.sja.org.uk). London SE1 9QB (0207 803 1100, fax: 020
7803 1111, website: www.mhf.org.uk, e-mail:
HAEMOPHILIA Haemophilia Society, First [email protected]).
Floor, Petersham House, 57a Hatton Garden,
London EC1N 8JG (020 7831 1020, fax: 020 LUPUS Lupus UK, St James House, Eastern
7405 4824, website: www.haemophilia.org.uk, Road, Romford, Essex RM1 3NH (01708
e-mail: [email protected]). 731251, fax: 01708 731252).
792 Appendix 2: Addresses

MARRIAGE GUIDANCE Relate (National MULTIPLE BIRTHS TAMBA (Twins and

Marriage Guidance), Herbert Gray College, Multiple Births Association), 2 The Willows,
Little Church Street, Rugby, Warwickshire Gardner Road, Guildford, Surrey GU1
CV21 3AP (01788 573241, fax: 01788 4PG (0870 770 3305, fax: 0870 770
535007, website: www.relate.org.uk, e-mail: 3303, website: www.tamba.org.uk, e-mail:
[email protected]). [email protected]).

MASTECTOMY See breast cancer care. MULTIPLE SCLEROSIS Multiple Sclerosis

Society of Great Britain and Northern Ireland,
MEDICAL ACCIDENTS Action for the MS National Centre, 372 Edgeware Road,
Victims of Medical Accidents (AVMA), London NW2 6ND (020 8438 0700, help-
44 High Street, Croydon, Surrey, CR0 line: 0808 800 8000, fax: 020 8438 0701,
1YB (0845 123 2352, fax: 020 8667 9065, website: www.mssociety.org.uk, e-mail: info@
website: www.avma.org.uk, e-mail: advice@ mssociety.org.uk).
avma.org.uk).
Multiple Sclerosis Resources Centre, 7 Peartree
MENINGITIS Meningitis Trust, Fern House, Business Centre, Peartree Road, Stanway,
Bath Road, Stroud, Gloucestershire GL5 3TJ Colchester CO3 5JN (01206 505444, 0800
(01453 768000, helpline: 080 8800 3344 783 0518, fax: 01206 505 449, website:
[24 hours], fax: 01453 768001, website: www.msrc.co.uk, e-mail: [email protected]).
www.meningitis-trust.org.uk, e-mail: info@
meningitis-trust.org.uk). MUSCULAR DYSTROPHY Muscular Dys-
trophy Campaign, 7/11 Prescott Place, London
Meningitis Research Foundation, Midland SW4 6BS (020 7720 8055, fax: 020 7498
Way, Thornbury, Bristol BS35 2BS (01454 0670, website: www.muscular-dystrophy.org,
281811, fax: 01454 281094, website: www. e-mail: [email protected]).
meningitis.org, e-mail: [email protected]).
MYALGIC ENCEPHALITIS The ME Associ-
MENTAL HEALTH Mental Aftercare Associ-
ation, 4 Top Angel, Buckingham Industrial
ation (MACA), 1st Floor, Lincoln House,
Park, Buckinghamshire MK18 1TH (0870 444
296302 High Holborn, London WC1V
8233, fax: 01280 821602, website: www.meas-
7JH (020 7061 3400, fax: 020 7061 3401,
sociation.org.uk, e-mail: meconnect@meas-
website: www.maca.org.uk, e-mail: info@
sociation.org.uk).
maca.org.uk).

Mental Health Act Commission See appendix 7: MYASTHENIA GRAVIS Myasthenia Gravis
statutory organisations. Association, Keynes House, Chester Park,
Alfreton Road, Derby DE21 4AS (01322
MIND (National Association for Mental 290219, fax: 01332 293641, website:
Health), 1519 Broadway, London E15 4BQ www.mgauk.org, e-mail: [email protected]).
(020 8519 2122, fax: 020 8522 1725, website:
www.mind.org.uk, e-mail: contact@ mind. MYOPATHY See muscular dystrophy.
org.uk).
NARCOLEPSY Narcolepsy Association (UK),
RETHINK, 30 Tabernacle Street, London UKAN, PO Box 13842, Penicuik EH25 8WX
EC2A 4DD (0845 456 0455, website: (0845 450 0394, fax: 0870 777 3039, website:
www.rethink.org, e-mail: [email protected]). www.narcolepsy.org.uk, e-mail: info@ narco
See also alzheimers disease.
lepsy.org.uk).

MIGRAINE Migraine Action Association NHS DIRECT HELPLINE (24 hours) 0845
(British Migraine Association), Unit 6, Oakley 4647.
Hay Lodge Business Park, Great Folds Road,
Great Oakley, Northamptonshire NN18 9AS NOTIFIABLE DISEASES See AIDS.
(01536 461 333, fax: 01536 461 444, website:
www.migraine.org.uk, e-mail: info@migraine. NURSING See appendix 8: professional
org.uk). organisations.

MOTOR NEURON DISEASE See paralysis. OSTEOARTHRITIS See arthritis.

 Appendix 2: Addresses 793

OSTEOGENESIS IMPERFECTA See brittle PHOBIAS National Phobics Society, Zion

bone disease. Community Resource Centre, 339 Stretford
Road, Hulme, Manchester M15 4ZY (0870
OSTEOPATHY See appendix 10: comple- 7700 456, fax: 0161 227 9862, website: www.
mentary and alternative medicine. phobics-society.org.uk, e-mail: nationalphobic
@btconnect.com).
OSTEOPOROSIS National Osteoporosis
Society, Camerton, Bath BA2 0PJ (01761 PHYSIOTHERAPY See appendix 8: profes-
471771, fax: 01761 471104, website: sional organisations.
www.nos.org.uk, e-mail: [email protected]).
PITUITARY-LINKED CONDITIONS The
PAGETS DISEASE National Association for Pituitary Foundation, PO Box 1944, Bristol
the Relief of Pagets Disease, 323 Manchester BS99 2UB (telephone and fax: 0845 450
Road, Walkden, Worsley, Manchester 0375, website: www.pituitary.org.uk, e-mail:
M28 3HH (0161 799 4646, fax: 0161 799 [email protected]).
6511, website: www.paget.org.uk, e-mail:
[email protected]). POISONS National Poisons Information
Service: 0870 600 6266.
PALATE MALFORMATIONS Cleft Lip and
Palate Association (CLAPA), 1st Floor, Green PSORIASIS Psoriasis Association, Milton
Man Tower, 332 Goswell Road, London House, 7 Milton Street, Northampton NN2
EC1V 7LQ (020 7833 4883, fax: 020 7833 7JG (helpline: 01604 711129, fax: 01604
5999, website: www.clapa.com, e-mail: 792894, e-mail: [email protected]).
[email protected]).
RABIES PET TRAVEL SCHEME Depart-
Maxillofacial and Dental Department, Great ment for Environment, Food and Rural Affairs
Ormond Street Hospital for Children, Great (DEFRA), 1a Page Street, London SW1P 4PQ
Ormond Street, London WC1N 3JH (020 (020 7904 6000, helpline: 0870 241 1710,
7813 8439, e-mail: [email protected]). website: www.defra.gov.uk/animalh/quaran-
tine/index.htm).
PARALYSIS Motor Neurone Disease Associ-
ation, PO Box 246, Northampton NN1 2PR RESTRICTED GROWTH Restricted Growth
(01604 250505, helpline: 0845 762 6262, fax: Association (RGA), PO Box 4744, Dorchester
01604 624726, website: www.mndassociation. DT2 9FA (telephone and fax: 01308 898445,
org, e-mail: enquiries@ mndassociation.org). website: www.restrictedgrowth.co.uk, e-mail:
[email protected]).
Spinal Injuries Association, Acorn House, 387
391 Midsummer Boulevard, Milton Keynes SICKLE-CELL ANAEMIA Sickle Cell Society,
MK9 3HP (0845 678 6633, helpline: 0800 54 Station Road, Harlesden, London NW10
980 0501, fax: 01908 608 492, website: 4UA (020 8961 7795, fax: 020 8961 8346,
www.spinal.co.uk, e-mail: [email protected]). website: www.sicklecellsociety.org, e-mail:
[email protected]).
Spinal Injuries Scotland, Festival Business
Centre, 150 Brand Street, Glasgow G51 1DH SMOKING ASH (Action on Smoking and
(0141 314 0056, fax: 0141 314 0057, website: Health), 102 Clifton Street, London EC2A
www.sisonline.org, e-mail: [email protected]). 4HW (020 7739 5902, fax: 020 7613
0531, website: www.ash.org.uk, e-mail:
PARKINSONISM Parkinsons Disease Society [email protected]).
of the United Kingdom, 215 Vauxhall Bridge
Road, London SW1V 1EJ (020 7931 8080, National Smoking Helpline: 0800 169 0 169
fax: 020 7233 9908, website: parkinsons. (07002300 daily).
org.uk, e-mail: [email protected]).
SPEECH DISORDERS AFASIC (Unlocking
PHENYLKETONURIA National Society for Speech and Language), 2nd floor, 5052 Great
Phenylketonuria (UK) Ltd (NSPKU), PO Box Sutton St, London EC1V 0DJ (020 7490
26642, London N14 4ZF (helpline: 0845 603 9410, helpline: 0845 355 5577, fax: 020 7251
9136, website: www.nspku.org, e-mail: 2834, website: www.afasic.org.uk, e-mail:
[email protected]). [email protected]).
794 Appendix 2: Addresses

SPEECH THERAPY See appendix 8: profes- website: www.listening-books.org.uk, e-mail:

sional organisations. [email protected]).

SPINA BIFIDA Association for Spina Bifida TINNITUS See deafness.

and Hydrocephalus, ASBAH House, 42 Park
Road, Peterborough PE1 2UQ (01733 555988, TOY LIBRARIES The National Association of
fax: 01733 555985, website: www.asbah.org, Toy and Leisure Libraries/Playmatters, 68
e-mail: [email protected]). Churchway, London NW1 1LT (020 7255
4600, fax: 020 7255 4602, website: www.natll.
Scottish Spina Bifida Association, 190 Queens- org.uk, e-mail: [email protected]).
ferry Road, Edinburgh EH4 2BW (0131 332
0743, fax: 0131 343 3651, website:
TRANS-SEXUALISM Gender Identity Con-
www.ssba.org.uk, e-mail: [email protected]).
sultancy (GICS), BM Box 5434, London
WC1N 3XX (telephone and fax: 020 7828
STAMMERING BSA (British Stammering
9575, website: www.members.aol.com/gic).
Association), 15 Old Ford Road, London
E2 9PJ (020 8983 1003, fax: 020 8983 3591,
website: www.stammering.org, e-mail: mail@ TRAVEL See appendix 3: travel and health.
stammering.org).
TUBEROUS SCLEROSIS Tuberous Sclerosis
STOMA See colostomy and ileostomy. Association, PO Box 9644, Bromsgrove,
Worcestershire B61 0FP (01527 871898,
STROKE See dysphasia. fax: 01527 579452, website: www.tuberous-
sclerosis.org, e-mail: support@tuberous-
SUDDEN INFANT DEATH SYNDROME sclerosis.org).
Foundation for the Study of Sudden Infant
Deaths, Artillery House, 1119 Artillery TURNERS SYNDROME The Turners Syn-
Row, London SW1P 1RT (0870 787 0885, drome Support Society (UK), 12 Irving Quad-
24-hour helpline: 0870 787 0554, fax: rant, Hardgate, Clydebank G81 6AZ (01389
0870 787 0725, website: www.sids.org.uk, 380 385, fax: 01389 380 384, website:
e-mail: [email protected]). www.tss.org.uk, e-mail: turner.syndrome@tss.
org.uk).
TALKING BOOKS Calibre, New Road,
Weston Turville, Aylesbury, Buckinghamshire VOLUNTARY ORGANISATIONS National
HP22 5XQ (01296 432339, fax: 01296 Council for Voluntary Organisations, Regents
392599, website: www.calibre.org.uk, e-mail: Wharf, 8 All Saints Street, London N1 9RL
[email protected]). (020 7713 6161, helpdesk: 0800 2798 798,
fax: 020 7713 6300, website: www.
Listening Books, 12 Lant Street, London SE1 ncvo-vol.org.uk, e-mail: helpdesk@ncvo-vol.
1QH (020 7407 9417, fax: 020 7403 1377, org.uk).
APPENDIX 3: TRAVEL AND HEALTH

INTRODUCTION mended immunisations (see VACCINE; IMMUN-

Whether a person is travelling abroad for busi- ISATION), climate, current health hazards and
ness or pleasure or is going to live in another currency allowances. They cannot, however, be
country, he or she should obtain information expected to give detailed individual advice,
about the climate, environment and health risks especially if the traveller has an existing medical
at their destination (including any stopovers condition.
that involve personal contacts with local There are many publications of help to trav-
people). Certain risks to health in another ellers, and authoritative advice is available from
country may always be present; sometimes haz- organisations listed in this appendix.
ards to health may be temporary because of a Travellers returning home who fall ill even
local epidemic or sudden adverse environ- several months later should always tell their
mental circumstance, such as a drought, earth- doctor where they have visited and when, in
quake or volcanic eruption, any of which can case their illness originated in another country.
cause problems in obtaining supplies of food,
clean water and medicine. USEFUL ADDRESSES
Any intending travellers with an existing ill- Tropical medical advice can be obtained by those
ness should find out from their doctors whether advising travellers from PHLS Communicable
they are fit to travel; whether the country of Disease Surveillance Centre, 61 Colindale
destination will admit them; whether they will Avenue, London NW9 5EQ (020 8200 6868);
be able to obtain appropriate treatment; and if London School of Hygiene and Tropical Medi-
so, how it will be paid for. cine, Keppel Street, London WC1E 7HT (020
Healthy travellers are also advised to enquire 7636 8636); Medical Advisory Services for
about health-care arrangements (including Travellers (MASTA) (www.masta.org); Com-
payments) in their destination country in case municable Diseases (Scotland) Unit, and
they fall ill while away. Some countries have Department of Tropical Medicine, Ruchill
reciprocal arrangements with the UK. Travellers Hospital, Glasgow G20 9NB (0141 946 7120);
should take sensible precautions about drinking Department of Infectious and Tropical Dis-
water and food, as hygiene standards vary eases, Birmingham Heartlands Hospital, Bord-
widely throughout the world. Pharmacists are esley Green East, Birmingham B9 5ST (0121
usually helpful with advice on over-the-counter 766 6611 enquiries from doctors and phar-
remedies for travel sickness and travellers macists only); Department of Infectious Dis-
tummy. eases and Tropical Medicine, North Manchester
Recent media publicity has alerted air travel- General Hospital, Delaunays Road, Manchester
lers, especially those flying long distances, about M8 6RB (0161 795 4567); and Liverpool
the risks of developing deep vein thrombosis School of Tropical Medicine, Pembroke Place,
(DVT), sometimes called economy-class syn- Liverpool L3 5QA (0151 708 9393).
drome. Sitting in a relatively confined position
for several hours can cause blood clots to form SOURCES OF OFFICIAL ADVICE
in the deep veins of the legs: ocasionally small The Department of Health produces annually
clots break away and are carried in the blood- the T4 booklet Health Advice for Travellers, and
stream to the lungs where they form clots in the this is available free from post offices or by tele-
circulation called pulmonary emboli (see PUL- phoning an order to 0800 555777. It contains
MONARY EMBOLISM) a potentially fatal dis- information on what compulsory and recom-
order. The risk of developing DVT is greatly mended immunisations apply to countries.
reduced by exercising the feet and knees while Advice is given on reducing health risks and on
sitting, by walking around the aircraft when entitlement to medical treatment at reduced
possible, drinking plenty of water but little or cost. Certificate E111 entitles nationals of
no alcohol, and wearing (properly fitting) elas- European Community countries to care in
tic stockings on the legs. Anyone who has other member states and the leaflet explains
already had a DVT should seek medical advice how to get this. Advice can be obtained from
before travelling by air. UK Department of Health Public Enquiries
Travel agents have a responsibility to advise Office, Richmond House, 79 Whitehall, Lon-
their clients about health risks, and the travel don SW1A 2NS (020 7210 4850); a free book-
trade has access to directories giving up-to-date let can be ordered from 0800 555777.
information on visa requirements, recom- Another source of advice is Foreign &
796 Appendix 3: Travel and Health

Commonwealth Office Travel Advice (website: membership free but voluntary contributions
www.fco. gov. uk/travel/countryadvice. gov/). welcome; publishes a directory of English-
The health departments in Scotland, Wales speaking doctors and leaflets on climate,
and Northern Ireland also produce information acclimatisation, immunisation, etc.); Air
on immunisation against infectious diseases; Transport Users Council, Room K705, CAA
this is published by HMSO and referred to as House, 45-59 Kingsway, London WC2B 6TE
the green book. (020 7240 6061 Care in the Air, advice for
The World Health Organisation in Geneva handicapped travellers); Intermedic, 77 Third
issues annually International Travel and Health Avenue, New York, United States of America
Vaccination Requirements and Health Advice, NY 10017 (members may obtain a list of
also available from HMSO. It is written primar- recommended English-speaking doctors in
ily for a medical readership. Designated yellow- many countries); US State Department website:
fever vaccination centres are distributed www.travel.state.gov; British Airways Medical
throughout the UK and details of these can be Service, Queens Building (N121), Heathrow
obtained from local departments of public Airport, Hounslow, Middlesex (020 8562
health, and in Scotland and Northern Ireland 7070, website: www.british-airways.com; Your
from health boards. Patient and Air Travel is useful for medical prac-
Most good bookshops contain a range of titioners); Diabeties UK, 10 Parkway, London
travel books and specific travel-health guides NW1 7AA (020 7424 1000 leaflets including
that contain information relating to health. travel guides concerning the more popular des-
Books may, however, become quickly out of tinations); Royal Association for Disability and
date because of changing circumstances and Rehabilitation (RADAR), 12 City Forum, 250
health regulations in different countries. The City Road, London EC1V 8AF (020 7250
Travellers Handbook, published by Wexas Ltd, 3222 leaflets available to help the handi-
is a good and comprehensive guide. Among capped arrange their travels); National Associ-
several specialist organisations giving travel ation for Maternal and Child Welfare Ltd, 1st
advice, for instance, to handicapped people, Floor, 4042 Osnaburgh Street, London NW1
and publishing books and leaflets, are the 3ND (020 7383 4117 also The Care of Babies
following: International Association for Med- and Young Children in the Tropics by D. Morley,
ical Assistance to Travellers (www.iamat.org Travelling with Children).
APPENDIX 4: COMMON MEDICAL TESTS AND PROCEDURES

ACETONE (URINE) respiratory effort, heart rate, and response to

Aim: Detection of diabetic ketoacidosis. stimulus. Points are awarded and resuscitation
Method: Using Acetest tablets, Chemstrip or started if needed. An Apgar score still low at 10
Multistix. or even 15 minutes represents a high risk for
Normal: Negative. Positive result can be pro- developing cerebral palsy.
voked by starvation and/or vomiting as well as
various metabolic diseases including diabetes BICARBONATE (WHOLE ARTERIAL BLOOD)
mellitus. Aim: Investigation of acidosis and alkalosis.
An important investigation when managing
ACID PHOSPHATASE patients with respiratory or renal disease or
Aim: Aid in diagnosis of prostatic cancer. anyone whose metabolism is profoundly dis-
Increased concentrations of this enzyme, which turbed, for example in any intensive care
is present in the kidney, semen, serum and the situation.
prostate gland, may occur in this condition. Normal: 1823 mmol/l.
Normal: 15 international units per litre.
BILIRUBIN
ADRENOCORTICOTROPHIC HORMONE Aim: To help assess liver function (and some-
(ACTH) (PLASMA) times degree of breakdown of blood cells
Aim: Diagnosis of Addisons disease, Cush- haemolysis)
ings syndrome and other disturbances of the A breakdown product of the blood pigment
hypothalamo-pituitary-adrenal axis. haemoglobin that is excreted in the bile, its
Normal: Sleepwake cycle of ACTH produc- concentration is raised in liver disease, obstruct-
tion, with highest levels at 06.0008.00 (soon ive jaundice, haemolytic anaemia and pulmon-
after getting up) and lowest levels at 21.00 ary infarction.
22.00 (after going to bed). Secretion is Normal: 217 m mol.1.
increased by pregnancy and stress.
BIOPSY OF TUMOURS
ALKALINE PHOSPHATASE Aim: Histological diagnosis of type of tumour
Aim: Evaluation of liver or bone disease. and malignancy.
This enzyme may be present in greater than Methods: Fine-needle and large-needle aspir-
normal amounts in several disorders including ation biopsy excision biopsy.
bone metastases, Pagets disease, rickets, liver
disease, pulmonary infarction and heart failure. CALCIUM (SERUM)
Normal: 30300 international units per litre. Aim: Diagnosis of hyperparathyroidism,
hypoparathyroidism, etc.
AMNIOCENTESIS Normal: See table B1 (page 804). Range may
Aim: Assessment of fetal maturity and diag- be affected by other drugs.
nosis of fetal abnormalities.
Method/hazards: With ultrasound guidance, a CARDIAC STRESS TEST
needle is inserted through the mothers abdom- Aim: Assessment of cardiac efficiency.
inal wall and uterus, and a specimen of amni- Method: Heart rate, blood pressure, and elec-
otic fluid withdrawn. There is a small risk to the trocardiograph are recorded continuously
fetus and the test should only be performed while the patient performs an incremental work
when essential. test. The test is stopped whenever requested,
e.g. in the presence of excessive dyspnoea, chest
AMYLASE (SERUM) pain.
Aim: Investigation of pancreatic and hepatic Contraindications include acute infection,
disease. recent myocardial infarction, unstable angina,
Normal: 25125 U/1 (units per litre). congestive heart failure, uncontrolled dys-
rhythmia, etc.
APGAR SCORE
Aim: Assessment of neonates need for CERVICAL CANCER SCREENING
resuscitation. Aim: Early detection of changes in cervical
Method: Evaluation at 1 minute and 5 min- cells, allowing earlier treatment.
utes after delivery of skin colour, muscle tone, Method: Starting 6 months after first inter-
798 Appendix 4: Common Medical Tests and Procedures

course, then at 3-yearly intervals for rest of life. Normal: See table B1 (pages 804805).
The test involves a cervical smear with a spat-
ula, the cells then being examined ERYTHROCYTE SEDIMENTATION
histologically. RATE (ESR)
Aim: Investigation and monitoring of fever,
CHOLECYSTOGRAM inflammatory, malignant, or autoimmune
An X-ray of the gall-bladder after the patient disease.
has taken a contrast medium by mouth; it is Method: Anticoagulated whole blood is used.
concentrated in the gall-bladder, thus enabling The result obtained may be influenced by
identification of abnormalities such as gall- numerous factors, notably various disorders and
stones, tumours and restricted patency of the different drugs.
cystic duct (which carries the bile from the gall- Normal:
bladder to the duodenum). male <50 <15 mm/h
>50 <20 mm/h
CHOLESTEROL female <50 <20 mm/h
Aim: A fatty substance present in several forms >50 <30 mm/h
in tissues and blood where its concentration
ranges from 3.67.8 mmol/l. Raised concentra- GLASGOW COMA SCALE (MODIFIED)
tions (hypercholesterolaemia) are often Aim: To test the depth of coma, particularly
associated with atheroma, which can cause following head injury, as a guide to the need for
cardiovascular or cerebral vascular disease, and neurosurgical intervention.
are linked with a high intake of saturated fats Method: Opening of the eyes, best verbal
and cholesterol, though damage to blood vessels response, and best motor response are scored
may be caused by one form of cholesterol called separately, giving a total quantitative index of
low-density lipoprotein (LDL) at a concentra- the level of cerebral dysfunction.
tion above 4.4 mmol/l.

CHORIONIC GONADOTROPHIN GLOMERULAR FILTRATION RATE

(URINE, FIRST MORNING SPECIMEN) (GFR)
Aim: Diagnosis of pregnancy. Aim: Investigation of renal function.
Methods: Agglutination inhibition assay: posi- Method: Plasma and urinary creatinine levels
tive in pregnancy 814 days after first missed are measured and the creatinine clearance rate
period. Monoclonal antibody test: positive in calculated. This corresponds closely to the
pregnancy 1418 days from conception. GFR, normally 120 ml/min in adults.

CHORIONIC VILLUS SAMPLING GLUCOSE (BLOOD, URINE)

Aim: Ascertainment of fetal chromosome Aim: Diagnosis and monitoring of diabetes
pattern. mellitus.
Method: A small sample of trophoblastic tissue Method: Stick tests available for urine and
is obtained from the placenta, by ultrasound blood samples.
guidance either transvaginally or transabdomi- Normal: See tables B1 and B4 (pages 804, 805).
nally, taken between the 9th and 11th weeks of
pregnancy. There is a small risk of abortion. GLUCOSE TOLERANCE TEST (ORAL)
Aim: Diagnosis of diabetes mellitus/impaired
CORDOCENTESIS glucose tolerance.
Aim: Investigation of the chromosome pattern Method: Pre-test patient, ensure no recent ill-
and haemoglobinopathies in mid-pregnancy. ness, accident, or surgery. Discontinue non-
Method: Blood is withdrawn from the umbil- essential drugs. Patient fasts for 1016 hours,
ical cord at about the 18th week of pregnancy then takes 75 g glucose over 5 minutes. Serum
and extensively analysed. glucose level is measured at 0, 30, 60, 90 and
120 minutes. The test should be performed in
ENZYME-LINKED IMMUNOSORBENT the morning.
ASSAY (ELISA) (URINE) Normal:
Aim: Diagnosis of presence of antibodies, for fasting 3.95.8 mmol/l
example to infective agents. 30 minutes 6.19.4 mmol/l
60 minutes 6.79.4 mmol/l
ERYTHROCYTE COUNT (WHOLE BLOOD) 90 minutes 5.67.8 mmol/l
Aim: Investigation of anaemia. 120 minutes 3.96.7 mmol/l
 Appendix 4: Common Medical Tests and Procedures 799

GLYCATED HAEMOGLOBIN (WHOLE blood cells), albumin (a key body protein made
BLOOD) in the liver) and alkaline phosphatase (an
Aim: Monitoring of diabetes mellitus. enzyme in bile) and aminotransferases or
Method: The test reflects the mean blood- transaminases (enzymes entering the blood fol-
glucose concentration over the previous 48 lowing liver-cell damage). Prothrombin time
weeks. It is a measure of long-term control and (see below) tests how well the blood clots: the
should be repeated at around 3-monthly process depends on the presence in the blood of
intervals. vitamin K (see APPENDIX 5: VITAMINS) which is
Normal: (In insulin-dependent diabetic) 79 produced by the normal liver; damage to liver
per cent. cells lengthens the time blood takes to clot.
X-ray and ultrasound assessment of liver and
HAEMATOCRIT (PACKED RED CELL gall-bladder structure are valuable, as are radio-
VOLUME) (WHOLE BLOOD) nuclide scanning and computed tomography.
Aim: Investigation of anaemia and
polycythaemia. LUMBAR PUNCTURE
Normal: See table B1 (page 804). Aim: To obtain samples of cerebrospinal fluid
(CSF) for investigation of central nervous sys-
HEPATITIS A ANTIGEN (SERUM) tem diseases, especially meningitis.
Aim: Diagnosis of hepatitis A infection. Method: With the patient lying on his or her
Normal: Negative. side, and under local anaesthesia, a long needle
Anti-HAV IgG appears about four weeks after is inserted between the third and fourth lumbar
infection and persists indefinitely. vertebrae. When performed correctly, a small
volume of fluid should flow out spontaneously;
HEPATITIS B SURFACE ANTIGEN this is collected and analysed (see table B2 [page
(SERUM) 805] for normal values).
Aim: Diagnosis of active or chronic hepatitis B The test should never be carried out in the
virus infection. presence of a raised CSF pressure, since it may
Normal: Negative. precipitate transtentorial or tonsillar herniation
in the brain.
HUMAN IMMUNODEFICIENCY VIRUS
(HIV) ANTIBODY (SERUM) MYOGLOBIN (SERUM)
Aim: Diagnosis of HIV infection. Aim: Diagnosis of myocardial infarction.
Method: HIV antibodies are usually detectable Normal:
from 4 weeks to 4 months after infection, and men 1992 mg/l
persist indefinitely. The test is by enzyme- women 1276 mg/l
linked immunosorbent assay (ELISA). The increase in value begins 3060 minutes
Normal: Negative. after onset of myocardial infarction and con-
tinues for 23 days.
IRON (SERUM)
Aim: Investigation of anaemia. POTASSIUM
Normal: See table B1 (page 804). Aim: To test for raised or lowered concentra-
tions of this essential element present as an elec-
LIVER FUNCTION TESTS trolyte in the blood. Abnormally low or high
The liver is a complex organ with metabolic, levels are found in a wide range of disorders.
excretory and protective functions that are Low: cirrhosis of liver, malnutrition, vomiting,
interdependent, so there is no single test to diarrhoea, diuresis, hyperadrenalism. High:
assess overall function. Liver biopsy, done under diabetic acidosis, hypoadrenalism, haemolysis,
local anaesthetic with entry through the skin, renal tubular defect, thrombocytosis.
gives helpful diagnostic information with little Normal: 3.55.0 m mol/l.
risk or discomfort to the patient. The procedure
enables liver tissue to be examined in the PROSTATE SCREENING TESTS
laboratory for structural changes and the pres- These tests for prostate cancer are still being
ence of abnormal cells. evaluated. One test is for the protein, prostate-
Several tests of blood chemistry detect specific antigen (PSA); its drawback is that it
changes in the various functions, as well as detects small areas of cancerous cells which
assessing the healthiness of liver cells. These might not necessarily go on to develop and
include tests on blood serum for the amounts of cause symptoms. Raised concentrations of acid
bilirubin (yellow breakdown products of red phosphatase occur in prostate cancer and in
800 Appendix 4: Common Medical Tests and Procedures

certain other conditions such as liver and bone eral disorders. Low: nephrosis, myxoedema,
disease. heart failure, diarrhoea and vomiting, diabetic
Normal: 04 ng/ml. acidosis, diuresis, adrenocortical insufficiency.
Ultrasound scanning and biopsy of the gland High: dehydration, diabetes insipidus, excessive
are useful tests. salt intake, diabetes mellitus.
Normal: 135145 mmol/l.
PROTHROMBIN TEST
Aim: To test quantitatively the amount of pro- THYROXINE, FREE (FT4) (SERUM)
thrombin in the blood based on the time it Aim: Measurement of thyroid function.
takes blood plasma to clot in the presence of Method: Various methods are used. The nor-
thromboplastin and calcium chloride. It meas- mal value is 1031 pmol/l, but varies with the
ures the integrity of the blood-clotting technique used.
function.
Normal: 1014 seconds. TROPONIN
The time is extended in haemophilia, serious Aim: Diagnosis of myocardial infarction.
liver disorders and when the diet is deficient in A raised level of this enzyme is now part of the
vitamin K. definition of myocardial infarction. False posi-
tives can occur, for example after strenuous
SKIN BIOPSY exercise such as marathon running.
Aim: Histological or immunofluorescent
examination of skin lesions, especially if there is TUBERCULIN SKIN TESTS
any suspicion of malignancy. Aim: Diagnosis of tuberculosis.
Method: Various techniques are used, depend- Method: Antigens of Mycobacterium tubercu-
ing on the amount of skin required and the losis are injected intradermally. In the Heaf test,
degree of doubt of the diagnosis. six skin punctures are then made through the
antigen. The test is read at 37 days and a posi-
SODIUM tive result is the appearance of four or more
Aim: To test for raised or lowered concentra- papules. It means that the patient has
tions of this essential element present as an elec- encountered the tubercle bacillus at some time
trolyte (sodium chloride) in the blood. in their life but not necessarily that they are
Abnormally low or high levels are found in sev- currently infected.
APPENDIX 5: VITAMINS

Introduction A general description of vit- of vitamin D]; 1,25-dihydroxy-cholecalciferol

amins is in the main text. Vitamins are divided [main active form of vitamin D]; precursor of
into those that are fat-soluble and those that are vitamin D2: ergosterol [plants]; of vitamin D3:
water-soluble. Fat-soluble vitamins are A, D, E 7-dehydrocholesterol [in skin])
and K; the water-soluble ones, B group and C. Functions Helps in absorption of calcium and
The water-soluble vitamin B group is com- phosphorus. Regulates blood concentrations of
plex. Although often found together in similar calcium. Promotes mineralisation of teeth and
types of food cereals, milk, liver, etc. they bones.
are not related chemically. These vitamins are Symptoms of deficiency Rickets in children.
all coenzymes organic (non-protein) com- Osteomalacia in adults.
pounds which, when the appropriate ENZYME is Symptoms of toxicity Calcification of soft tis-
present, have an essential function in the chem- sues, hypercalcaemia, renal stones, loss of
ical reaction catalysed by the enzyme. The weight and appetite, nausea and fatigue, failure
vitamin B group comprises B1 (thiamine, aneu- of growth.
rine), B2 (riboflavin), B3 (niacin, nicotinic acid), Sources Cod and halibut liver oils, bony fish,
B6 (pyridoxine), B12 (cobalamin, cyanocobal- egg yolk, fortified milk, butter and poly-
amin), biotin, folacin (folic acid) and panto- unsaturated margarine. Sunlight acts on ergos-
thenic acid. terol in plants to produce vitamin D2 and on
Unlike fat-soluble vitamins, the water- the skin to produce vitamin D3.
soluble ones are not stored in large amounts in Recommended daily amounts (IUs)
the body so deficiency of these is more likely. Babies and children 300400
Subjects aged1125 400
Fat-soluble vitamins Subjects over 25 200
Pregnant and lactating women 400
VITAMIN A (Preformed specific compounds:
RETINOL, retinal, RETINOIC ACID. Precursor: VITAMIN E
CAROTENE) Functions Prevents oxidation of vitamin A in
Functions Maintenance of epithelial cells and gut. Protects red blood cells from haemolysis.
mucous membranes. Constituent of visual pur- Maintains cell membranes by reducing the oxi-
ple (for night vision). Necessary for normal dation of polyunsaturated fats.
growth, development and reproduction. Main- Symptoms of deficiency Breakdown of red
tenance of immune system. blood cells.
Symptoms of deficiency Keratinised skin, dry Symptoms of toxicity Headache, nausea,
mucous membranes, xerophthalmia. Night longer blood-clotting times.
blindness. Susceptibility to disease. Food sources Wheat germ, vegetable oils, leg-
Symptoms of toxicity Dry skin. Loss of appe- umes, nuts, whole grains, fish, green, leafy
tite and hair, enlarged spleen and liver, vegetables.
abnormal pigmentation of skin. Fetal Recommended daily allowances (mg)
malformations. Babies and children 37
Food sources Preformed vitamin A Liver, espe- Boys (>11 years) and men 10
cially cod and halibut liver oil; egg yolk; milk Girls (>11 years) and non-pregnant women 8
and butter. Carotene Dark-green, leafy veget- Pregnant and lactating women 1012
ables, especially spinach, broccoli, kale. Deep
orange vegetables and fruits, especially carrots, VITAMIN K
tomatoes, apricots. (PHYTOMENADIONE, phylloquinone)
Recommended daily amounts (IUs*) Functions Necessary for the formation of pro-
Babies and children 1,8753,500 thrombin and other factors necessary for blood
Boys (>11 years) and men 5,000 clotting.
Girls (>11 years) and women 4,000 Symptoms of deficiency Haemorrhage.
Lactating women 6,0006,500 Symptoms of toxicity Haemolytic anaemia,
*International Units liver damage.
Sources Dark-green leafy vegetables, especially
VITAMIN D (ERGOCALCIFEROL or CALCIFEROL alfalfa, spinach, cabbage. Cauliflower. Egg yolk.
[vitamin D2]; cholecalciferol [vitamin D3]; 25- Soybean oil. From synthesis by intestinal
hydroxycholecalciferol [main circulating form bacteria.
802 Appendix 5: Vitamins

Recommended daily amounts (g) VITAMIN B3 (niacin, NICOTINIC ACID [a

Babies and children 520 derivative of pyridine])
Boys (>11 years) and men 4580 Functions Part of two important enzymes
(increasing with age) regulating energy metabolism. Promotes good
Girls (>11 years) and women 4565 physical and mental health and helps maintain
(increasing with age) the health of the skin, tongue and digestive
Pregnant and lactating women 65 system.
Symptoms of deficiency Pellagra, gastrointest-
CHOLINE The basic compound participates in inal disturbances, photosensitive dermatitis,
the synthesis of LECITHIN and other phospho- depression.
lipids as well as of acetylcholine. Choline, Symptoms of toxicity Flushing, loss of appe-
which helps to transport fat in the body, and is tite, nausea and vomiting, abnormal energy
essential to life, is sometimes classed as a vita- metabolism, anaphylaxis, circulatory collapse.
min, but the body is able to produce the Sources Whole grain flour, enriched white
compound. flour, legumes. Brewers yeast. Meat; heart,
liver, kidney.
Water-soluble vitamins Recommended daily amounts (mg)
Babies and children 513
VITAMIN B1 (THIAMINE, ANEURINE) Boys (>11 years) and men 1520
Functions Has role in carbohydrate metabol- Girls (>11 years) and women 1315
ism. Helps nervous system, heart and muscles Pregnant women 17
to function properly. Promotes appetite and Lactating women 20
functioning of digestive tract.
Symptoms of deficiency Polyneuritis, beriberi, VITAMIN B6 (PYRIDOXINE [pyridoxal is a
fatigue, depression, poor appetite and function- coenzyme of pyridoxine])
ing of digestive tract. Functions Important in metabolism of pro-
Symptoms of toxicity Anaphylactic shock, teins, amino acids, carbohydrate and fat. Essen-
lethargy, ataxia, nausea, hypotension. tial for growth and health.
Sources Whole grains, wheat germ, enriched Symptoms of deficiency Not fully known but
white-flour products, legumes. Brewers yeast. possibly convulsions, peripheral neuropathy,
Heart, liver, kidney; pork. secondary pellagra, depression and oral
Recommended daily amounts (mg) symptoms.
Babies and children 0.31.0 Symptoms of toxicity Reduces prolactin secre-
Boys (>11 years) and men 1.21.5 tion, which is important for milk pro-duction.
Girls (>11 years) and women 1.01.1 Damage to sensory nerves. Liver damage.
Pregnant women 1.5 Sources Whole grains, potatoes, green veget-
Lactating women 1.6 ables, maize. Liver; red meat.
Recommended daily amounts (mg)
VITAMIN B2 (RIBOFLAVIN [formerly vitamin Babies and children 0.31.4
G]) Boys (>11 years) and men 1.72.0
Functions Essential for certain enzyme systems Girls (>11 years) and women 1.41.6
important in the metabolism of food (carbo- Pregnant women 2.2
hydrate, protein and fat). Lactating women 2.1
Symptoms of deficiency Inflamed tongue,
scaling and burning skin, sensitive eyes, angular VITAMIN B12 (cobalamin, CYANOCOBALAMIN)
stomatitis and cheilosis, cataracts. Functions Important for haemoglobin syn-
Symptoms of toxicity None recorded. thesis. Essential for normal functioning of all
Sources Green, leafy vegetables, peanuts, cells, especially of the nervous system, bone
whole grains. Milk and its products, eggs, liver, marrow, and gastrointestinal tract.
kidney, heart. Symptoms of deficiency Pernicious anaemia,
Recommended daily amounts (mg) subacute degeneration of the spinal cord, vari-
Babies and children 0.41.2 ous psychological disorders, possibly loss of
Boys (>11 years) and men 1.41.8 appetite (anorexia).
Girls (>11 years) and women 1.21.3 Symptoms of toxicity Not known.
Pregnant women 1.6 Sources Not found in significant amounts in
Lactating women 1.71.8 plant foods. Eggs, dry milk and milk products.
Meat; liver, kidney, heart.
 Appendix 5: Vitamins 803

Recommended daily amounts (g) VITAMIN B COMPLEX (PANTOTHENIC ACID)

Babies and children 0.31.4 Functions An essential component of
Subjects over 11 years 2.0 coenzyme A, which is a key factor in many of
Pregnant women 2.2 the bodys metabolic activities.
Lactating women 2.6 Symptoms of deficiency Rare, but in a trial on
volunteers malaise, abdominal discomfort and
VITAMIN B COMPLEX (folate, FOLIC ACID) sensory disturbances occurred.
Functions Formation of red blood cells. Nor- Symptoms of toxicity Not known.
mal function of gastrointestinal tract. Helps in Sources Widely distributed in foodstuffs.
metabolism of protein. Recommended daily amounts Adults prob-
Symptoms of deficiency Possible neural tube ably need about 4 to 7 mg/day.
defect in fetuses, anaemia.
Symptoms of toxicity Possible hypersensitivity VITAMIN C (ASCORBIC ACID, dehydroascorbic
reactions. acid)
Sources Dark-green, leafy vegetables, legumes, Functions Protects against infection and helps
whole grains. Yeast. Kidneys, heart and in wound healing. Important for tooth dentine,
pancreas. bones, cartilage, connective tissue and blood
Recommended daily amounts (g) vessels.
Babies and children 25100 Symptoms of deficiency Scurvy, anaemia,
Boys (>11 years) and men 150200 swollen and bleeding gums, loose teeth, bruis-
Girls (>11 years) and women 150180 ing (from rupture of small blood vessels).
Pregnant women 400 Symptoms of toxicity Kidney stones.
Lactating women 260280 Sources Citrus fruits, tomatoes, strawberries,
currants, green, leafy vegetables, broccoli, cab-
VITAMIN B COMPLEX (BIOTIN) bage, potatoes.
Functions Takes part in amino-acid and fatty- Recommended daily amounts (mg)
acid metabolism. Babies and children 3045
Symptoms of deficiency Rare: dermatitis, Subjects over 11 years 5060
soreness of the tongue, dependency. Pregnant women 70
Symptoms of toxicity Not known. Lactating women 9095
Sources Egg yolk, cauliflower, kidney, legumes,
liver, nuts, yeasts.
Recommended daily amounts 150300 g.
APPENDIX 6: MEASUREMENTS IN MEDICINE

Introduction This appendix gives a brief MULTIPLES AND SUBMULTIPLES

description of the System of International Units Factor Prefix Abbreviation
(SI UNITS) and tables of normal values for the 106 mega m
composition of body fluids and body wastes. In 103 kilo k
addition there are tables of desirable body 101 deci d
weights according to age (infants) and height 102 centi c
and body build (adults). 103 milli m
Readers should bear in mind that normal 106 micro
values may vary, sometimes quite widely, in 109 nano n
healthy individuals. Furthermore, the relation- 1012 pico p
ships between height, build and weight are flex-
ible and should not be treated as absolute B: Normal body values
targets. 1 BLOOD (PLASMA, SERUM)
Biochemical values
A: SI units and multiples The Inter- Substance Approximate adult
national System of Units (Systme Inter- range
national) usually referred to as SI units, was Ammonium 2448 mol/l
introduced in the 1970s and has been expanded Ascorbate 4580 mol/l
and developed since. Now the SI units and Base excess 02 mmol/l
symbols and certain units derived from the Bicarbonate (serum) 2329 mmol/l
system are used for measurements in most sci- Bilirubin, total (plasma) 517 mol/l
entific disciplines and are an integral part of Caeruloplasmin (serum) 1.52.9 mol/l
scientific language. The units comprise three Calcium (serum) 2.12.6 mmol/l
classes: base units, supplementary units and Carbon dioxide tension
derived units. The seven base units are the (Pco2) 4.56.1 kPa
metre (length), kilogram (weight), second -carotene 0.95.6 mmol/l
(time), ampere (electric current), kelvin (tem- Chloride (serum) 95105 mmol/l
perature), mole (amount of substance: one Cholesterol (serum) 3.96.5 mmol/l
mole of a compound has a mass equal to its Copper (serum) 1324 mmol/l
molecular weight in grams) and candela (lumi- Cortisol (plasma) 280700 nmol/l
nous intensity). The SI units used commonly in Creatine (serum) 1561 mol/l
medicine are shown below. Some traditional Creatinine (serum) 62133 mol/l
measurements are still used, one example being Fibrinogen (plasma) 5.911.7 mol/l
millimetres of mercury (Hg) which is the unit Folate (serum) 1148 nmol/l
for blood pressure. Glucose, fasting (serum) 3.96.4 mmol/l
Iron (serum) 1331 mol/l
SI UNITS COMMONLY USED IN Iron binding capacity,
MEDICINE total (serum) 4573 mol/l
Quantity SI unit (abbreviation) Lactate 0.61.8 mmol/l
Length metre (m) Lipids, total (plasma) 4.010.0 g/l
Area square metre (m2) Osmolality (serum) 280295 mmol/kg
Volume cubic metre (m3) = 100 Oxygen tension (Po2) 1114 kPa
litre (l or L) pH 7.357.45
Mass kilogram (kg) Potassium (serum) 3.55.0 mmol/l
Amount of substance mole (mol) Prostate specific antigens 04 ng/l
at molecular level Protein (serum)
Energy joule (J) total 6282 g/l
Pressure pascal (Pa) albumin 3555 g/l
Force newton (N) globulin 2535 g/l
Time second (s) Pyruvate 4580 mol/l
Frequency hertz (Hz) Sodium (serum) 135145 mmol/l
Power watt (w) Triglycerides (serum) 0.31.7 mmol/l
Temperature degree Celsius (C) Urate (serum) 0.10.4 mmol/l
Urea (serum) 4.08.0 mmol/l
 Appendix 6: Measurements in Medicine 805

Haematological values Creatinine 917 mmol/24 hours

Measurement Adult daily range Glucose 11 mmol/l
Bleeding time (Ivy) 5 minutes Magnesium 3.04.5 mmol/24 hours
Cell counts Osmolality 381400 mmol/kg water
Erythrocytes, men 4.66.2 10 12/l pH 4.68.0
women 4.25.8 10 12/l Phosphorus
Leucocytes, total 4.511.0 10 9/l (inorganic) 2045 mmol/24 hours
Differential: Porphyrins:
Neutrophils 3.06.5 10 9/l Coproporphyrin 77380 nmol/24 hours
Lymphocytes 1.53.0 10 9/l Uroporphyrin 1236 nmol/24 hours
Monocytes 0.30.6 10 9/l Potassium 25100 mmol/24 hours
Eosinophils 50300 10 6/l Protein 10150 mg/24 hours
Basophils 1560 10 6/l Sodium 130260 mmol/24 hours
Platelets 150350 10 9/l Urate 1.23.0 mmol/24 hours
Reticulocytes 2575 10 9/l 5 TEMPERATURE
Haemoglobin, men 2.22.8 mmol/l Normal, adults 36.637.2 C
(13.518.0 g/dl) children 36.537.5 C
women 1.92.5 mmol/l infants 37.538.5 C
(11.516.0 g/dl) Hyperpyrexia (q.v.) 41.6 C
Haematocrit, men 0.400.54 Hypothermia (q.v.) 35.0 C
women 0.370.47 NB The temperature in the axilla or groin is
Mean corpuscular about 0.5 C lower, and in the rectum about
haemoglobin (MCH) 0.420.48 fmol 0.5 C higher, than the oral temperature.
Mean corpuscular volume
(MCV) 80105 fl C: Desirable body weights and
Mean corpuscular heights
haemoglobin
concentration (MCHC) 0.320.36 1 CHILDREN, BIRTH TO 5 YEARS, SEXES
Red cell life span (mean) 120 days COMBINED
Age Standard weight Standard height
2 CEREBROSPINAL FLUID (kg) (cm)
Measurement Approximate adult range 0 (birth) 3.4 55
Cells 5 l; all mononuclear 1 month 4.3
Chloride 120130 mmol/l 2 months 5.0
Glucose 2.84.2 mmol/l 3 months 5.7 60
Pressure 70180 mm water 4 months 6.3
Protein, total 0.20.5 g/l 5 months 6.9
IgG 0.14 of total protein 6 months 7.4 65
8 months 8.4
3 FAECES 10 months 9.3
Measurement Approximate adult range 12 months 9.9 75
Bulk 100200 g/24 hours 18 months 11.3 80
Dry matter 2332 g/24 hours 2 years 12.4 85
Fat, total 6.0 g/24 hours 3 years 14.5 95
Nitrogen, total 2.0 g/24 hours 4 years 16.5 100
Urobilinogen 40280 mg/24 hours 5 years 18.4 105
Water 0.65 g/24 hours

4 URINE
Measurement Approximate adult range
Albumin 0.21.5 mol/24 hours
Calcium 2.57.5 mmol/24 hours
Catecholamines
(adrenalin) 55 nmol/24 hours
Chloride 110250 mmol/24 hours
Copper 0.8 mol/24 hours
Creatine, men 300 mol/24 hours
women 700 mol/24 hours
806 Appendix 6: Measurements in Medicine

2 ADULTS, ACCORDING TO HEIGHT AND BUILD

Men Women
Height Build (weight in kg) Height Build (weight in kg)
(m) Small Medium Large (m) Small Medium Large
1.550 50.854.4 53.558.5 57.264.0 1.425 41.744.5 43.548.5 47.254.0
1.575 52.255.8 54.960.3 58.565.3 1.450 42.645.8 44.549.9 48.155.3
1.600 53.557.2 56.261.7 59.967.1 1.475 43.547.2 45.851.3 49.456.7
1.625 54.958.5 57.663.0 61.268.9 1.500 44.948.5 47.252.6 50.858.1
1.650 56.260.3 59.064.9 62.670.8 1.525 46.349.9 48.554.0 52.259.4
1.675 58.162.1 60.866.7 64.473.0 1.550 47.651.3 49.955.3 53.560.8
1.700 59.964.0 62.668.9 66.775.3 1.575 49.052.6 51.357.2 54.962.6
1.725 61.765.8 64.470.8 68.577.1 1.600 50.354.0 52.659.0 56.764.4
1.750 63.568.0 66.272.6 70.378.9 1.625 51.755.8 54.461.2 58.566.2
1.775 65.369.9 68.074.8 72.181.2 1.650 53.557.7 56.263.0 60.368.0
1.800 67.171.7 69.977.1 74.483.5 1.675 55.359.4 58.164.9 62.169.9
1.825 68.973.5 71.779.4 76.285.7 1.700 57.261.2 59.966.7 64.071.7
1.850 70.875.7 73.581.6 78.588.0 1.725 59.063.5 61.768.5 65.873.9
1.875 72.677.6 75.783.9 80.790.3 1.750 60.865.3 63.570.3 67.676.2
1.900 74.479.4 78.086.2 82.692.5 1.775 62.667.1 65.372.1 69.478.5

An individual assessment of a persons size can be made by using the BODY MASS INDEX (BMI). (See
also OBESITY.)
APPENDIX 7: STATUTORY ORGANISATIONS

Names, addresses and functions of a selection of The GMC is the medical professions regula-
government-funded bodies whose activities are tory body and also has responsibility for setting
related to the provision of health care in the educational and ethical standards. The council
United Kingdom. is a statutory body, set up in 1858, which is
responsible to the Privy Council. It has powers
AUDIT COMMISSION, 1 Vincent Square, Lon- under the Medical (Professional Performance)
don SW1P 2PN (020 7828 1212, website: Act 1995 to act in respect of doctors whose
www.auditcommission.gov.uk). Appoints aud- professional performance is seriously deficient.
itors to local authorities, health authorities and The GMC has the authority to investigate and,
NHS trusts and promotes studies to encourage where appropriate, discipline doctors for pro-
economy, efficiency and effectiveness in the fessional misconduct. The council has proposed
NHS and local government. a revalidation procedure to monitor doctors
continuing professional competence during
CLINICAL STANDARDS ADVISORY GROUP, their careers.
Room 19, Wellington House, 133155 Water-
loo Road, London SE1 8UG (020 7972 4918). GENERAL OPTICAL COUNCIL, 41 Harley Street,
Advises health ministers and the NHS on London W1N 2DJ (020 7580 3898, website:
standards of clinical care for, access to and avail- www.optical.org). Registers and regulates the
ability of services to NHS patients professions of ophthalmic opticians and dis-
pensing opticians.
COMMITTEE ON SAFETY OF MEDICINES See
MEDICINES CONTROL AGENCY. HEALTH AND SAFETY COMMISSION AND
HEALTH AND SAFETY EXECUTIVE (HSE), Rose
COMMON SERVICES AGENCY FOR THE SCOT- Court, 2 Southwark Bridge, London SE1 9HS
TISH HEALTH SERVICE, Trinity Park House, (020 7717 6000, information line: 08701
South Trinity Road, Edinburgh EH5 3SE 545500, fax: 020 717 6717, website:
(0131 552 6255, website: www.show. www.hse.gov.uk, e-mail: hseinformationserv-
scot.nhs.uk). Provides the NHS in Scotland ices@ natbrit.com). Both these bodies are dedi-
with a range of services and products as directed cated to securing the health, safety and welfare
and ensures they are delivered to customer of persons at work and to protect the public
requirements and to defined standards of generally against risks to health or safety arising
quality. from work activities. The HSE has powers to
inspect the health and safety arangements of
COUNCIL FOR NURSING AND MIDWIFERY (for- organisations and, where these fail to meet
merly UNITED KINGDOM CENTRAL COUNCIL statutory requirements or where accidents have
FOR NURSING, MIDWIFERY AND HEALTH VISIT- occurred, it can investigate and prosecute
ING), 23 Portland Place, London W1N 4JT offenders.
(020 7637 7181). A regulatory body which sets
standards for education and conduct of the HEALTHCARE COMMISSION, Finsbury Tower
nursing, midwifery and health-visiting profes- 1035 Bunhill Row, London EC1Y 8TG (020
sions and maintains the professional registers. 7448 9200, website: www.healthcarecommis-
sion.org.uk). A statutory body set up in 1999
GENERAL DENTAL COUNCIL, 37 Wimpole and accountable to the Secretary of State for
Street, London W1G 8DQ (020 7887 3800, e- Health. It provides an independent guarantee
mail: [email protected]). Maintains a that systems are in place to monitor and
register of dentists; promotes high standards of improve clinical standards in general practice,
dental education at all stages and of professional community services and hospitals. The com-
conduct among dentists. The council has mission provides national leadership to develop
disciplinary powers in respect of dentists and disseminate clinical governance principles
professional conduct. and to monitor local arrangements. It com-
prises 14 members (including a chairman) and
GENERAL MEDICAL COUNCIL (GMC), Regents these include health professionals and academ-
Place, 350 Euston Rd, London NW1 3JN ics, along with eight lay members. The commis-
(0845 357 8001, website: www.gmc-uk.org). sions activities cover England and Wales; Scot-
808 Appendix 7: Statutory Organisations

lands equivalent to the HCC is the Clinical safeguard public health by ensuring that
Standards Board. branded and non-branded human medicines in
the UK meet appropriate criteria of safety, qual-
HEALTH DEVELOPMENT AGENCY (HDA), Trev- ity and efficiency. It applies standards laid
elyan House, 30 Great Peter Street, London down in the Medicines Act of 1968 and by
SW1P 2HW (020 7222 5300, fax: 020 7413 European Community legislation. The agency
8900, website: www.hda-online.org.uk, e-mail: seeks advice from expert professional commit-
[email protected]). tees such as the Committee on Safety of Medi-
cines and the Medicines Commission, both
HEALTH PROFESSIONS COUNCIL (FORMERLY statutory committees based at the same address
COUNCIL FOR PROFESSIONS SUPPLEMENTARY as the MCA. The MCA operates the Yellow
TO MEDICINE), Park House, 184 Kennington Card reporting scheme for adverse reactions to
Park Road, London SE11 4BU (020 7582 drugs.
0866, website: www.hpc-uk.org.com). Super-
vises the professional education and discipline MENTAL HEALTH ACT COMMISSION, Maid
in chiropody, dietetics, medical laboratory sci- Marian House, 56 Houndsgate, Nottingham
ences, occupational therapy, orthoptics, physio- NG1 6BG (0115 943 7100, fax: 0115 943
therapy and radiography. 7001, website: www.mhac.trent.nhs.uk, e-mail:
[email protected]). Set up in 1983
HEALTH SERVICE COMMISSIONER FOR ENG- as a special health authority, the commission is
LAND (OMBUDSMAN), 11th Floor, Millbank responsible for protecting the interests of
Tower, Millbank, London SW1P 4QP (020 patients detained in England and Wales under
7217 4051, fax: 020 7217 4000, website: the Act. Scotland and Northern Ireland have
www.ombudsman.org.uk, e-mail: OHSC.En- separate legislation.
[email protected]). Appointed by
the government, the Commissioner investigates MENTAL WELFARE COMMISSION FOR SCOT-
complaints about services provided under the LAND, Argyle House, 3 Lady Lawson Street,
NHS and presents regular reports to Edinburgh EH3 9SH (0131 222 6111, website:
Parliament. www.mwcscots.org.uk). This body has similar
responsibilities in Scotland to those of the Men-
HUMAN FERTILISATION AND EMBRYOLOGY tal Health Act Commission in England and
AUTHORITY, Paxton House, 30 Artillery Lane, Wales (see above).
London E1 7LS (020 7377 5077, website:
www.hfea.gov.uk). A government licensing NATIONAL AUDIT OFFICE (NAO), 157197
body concerned with storage of human gametes Buckingham Palace Road, Victoria, London
(sperm and eggs) and embryos, research on SW1W 9SP (020 7798 7000, website:
human embryos, and any infertility treatment www.nao.gov.uk). The NAO audits public
which involves the use of donated gametes or expenditure and is accountable to Parliament
embryos created outside the body. that money is spent for the purpose intended by
Parliament and is properly accounted for.
MEDICAL RESEARCH COUNCIL (MRC), 20 Park
Crescent, London W1N 4AL (020 7636 5422, NATIONAL BLOOD AUTHORITY (NBA), Oak
website: www.mrc.ac.uk). The MRCs main House, Reeds Crescent, Watford, Herts. WD1
objectives are to promote the balanced devel- 1QH (01923 486800, fax: 01923 486801,
opment of medical and related biological website: www.blood.co.uk). Created in 1993 to
research so as to improve health care. It employs manage all NHS blood services, the NBA man-
its own research staff in more than 40 research ages 15 regional transfusion services. Its object-
establishments, and also provides grants to ives are to maintain blood and blood-product
individual scientists. supply, based on a system of two million volun-
tary donors; and to ensure a safe, high-quality,
MEDICINES COMMISSION See MEDICINES cost-effective supply of blood and blood prod-
CONTROL AGENCY. ucts for national needs.

MEDICINES CONTROL AGENCY (MCA), Market NATIONAL INFECTION CONTROL AND HEALTH
Towers, Nine Elms Lane, London SW8 5NQ PROTECTION AGENCY See entry in main dictionary.
(020 7273 0393, website: www.mca.gov.uk).
The MCA is an executive agency of the NATIONAL INSTITUTE FOR CLINICAL EXCEL-
Department of Health. Its main function is to LENCE (NICE), 90 Long Acre, Covent Garden,
 Appendix 7: Statutory Organisations 809

London WC2E 9RZ (020 7849 3444, website: laboratories in England and Wales is led by
www.nice.org.uk). A special NHS health the headquarters complex at Colindale, where
authority which produces guidelines for clinical the Central Public Health Laboratory and
treatments in hospitals and general practice Communicable Disease Surveillance Centre is
based on scientific evidence. It appraises new sited.
and existing technologies and promotes clinical
audit and confidential inquiries into clinical STANDING MEDICAL ADVISORY COMMITTEE,
practices in the NHS. As well as a chairman, Department of Health, Room 919, Wellington
seven non-executive directors and four execu- House, 135155 Waterloo Road, London SE1
tives, NICE has a partners council comprising 8UG (020 7972 4919); STANDING NURSING
representatives from patient and care groups, AND MIDWIFERY ADVISORY COMMITTEE,
the health professions, NHS interests and Department of Health, Room 919, Wellington
health-care industries. House, 135155 Waterloo Road, London SE1
8UG (020 7972 4919); and STANDING
NATIONAL RADIOLOGICAL PROTECTION PHARMACEUTICAL ADVISORY COMMITTEE,
BOARD, Chilton, Didcot, Oxfordshire OX11 Department of Health, Room 301, Richmond
0RQ (01235 831600, website: www.nrpb. House, 79 Whitehall, London SW1A 2NS
org.uk). An independent government body (020 7210 5117). The three standing advisory
which acts as the national point of authoritative committees advise health ministers in England
reference for radiological protection. and Wales on matters relating to medicine,
nursing, midwifery and pharmaceutical
services.
NORTHERN IRELAND CENTRAL SERVICES
AGENCY FOR THE HEALTH AND SOCIAL SER-
STANDING COMMITTEE ON POSTGRADUATE
VICES, 2527 Adelaide Street, Belfast BT2
MEDICAL AND DENTAL EDUCATION (SCOPME),
8FH (02890 324431). Offers a range of ser-
One Park Square West, London NW1 4IJ (020
vices to GPs and the four health and social-
7935 3916). There are separate councils for
services boards.
Scotland, Wales and Northern Ireland. Advises
the secretary of state on the delivery of post-
PRESCRIPTION PRICING AUTHORITY, Bridge graduate and continuing medical and dental
House, 152 Pilgrim Street, Newcastle upon education.
Tyne NE1 2SN (0191 232 5371, website:
www.ppa.org.uk). The authoritys main func- UNITED KINGDOM CENTRAL COUNCIL FOR
tions are to calculate and make payments to NURSING, MIDWIFERY AND HEALTH VISITING
dispensing pharmacists and doctors in England See COUNCIL FOR NURSING AND MIDWIFERY.
for NHS prescriptions, and to provide informa-
tion on prescribing and dispensing to NHS GPs UNITED KINGDOM TRANSPLANT SUPPORT
and NHS authorities. SERVICE AUTHORITY, Fox Den Road, Stoke
Gifford, Bristol BS12 6RR (0117 975 7575,
PUBLIC HEALTH LABORATORY SERVICE (PHLS), website: www.uktransplant.org.uk). A special
Headquarters Office, 61 Colindale Avenue, health authority providing a support service for
London NW9 5DF (020 8200 1295, website: the matching, allocating and distribution of
www.phls.co.uk). The PHLS co-operates with donor organs for transplant.
the NHS to provide national facilities for the
diagnosis, prevention and control of infectious YELLOW CARD SCHEME See MEDICINES CON-
and communicable diseases. The network of 50 TROL AGENCY.
APPENDIX 8: PROFESSIONAL ORGANISATIONS

A selection of health-related non-statutory pro- royal college of paediatrics and

fessional organisations. child health, 50 Hallam Street, London
W1W 6DE (020 7307 5600, website:
Specialist organisations of the med- www.rcpch.ac.uk).
ical profession The royal colleges and fac-
ulties in the list that follows represent the range royal college of pathologists, 2 Carlton
of recognised specialties in medicine in the House Terrace, London SW1Y 5AF (020 7451
United Kingdom. They are responsible for set- 6700, website: www.rcpath.org, e-mail:
ting the criteria for specialist training; for [email protected]).
approving and monitoring training posts in the
NHS; for organising appropriate specialist royal college of physicians, 11 St Andrews
examinations; and for admitting successful Place, London NW1 4LE (020 7935 1174,
candidates to membership or fellowship of the website: www.rcplondon.ac.uk).
relevant institution. This enables doctors to be
registered with the General Medical Council royal college of physicians of edinburgh,
as specialists. Representatives of the colleges and 9 Queen Street, Edinburgh EH2 1JQ (0131
faculties join with representatives of hospital 225 7324, website: www.rcpe.ac.uk).
doctors in the British Medical Association and
the British Dental Association to form the Joint
royal college of physicians and surgeons
Consultants Committee. This Committee
of glasgow, 234242 St Vincent Street,
meets regularly with ministers and officials
Glasgow G2 5RJ (0141 221 6072, website:
from the UKs health departments and NHS
www.rcpsglasg.ac.uk).
management to discuss the provision and
standards of NHS specialist care along with the
postgraduate educational requirements of NHS royal college of physicians of ireland, 6
doctors. Kildare Street, Dublin 2 (00353 1 6616677,
The royal colleges and faculties also have an website: www.rcpi.ie).
umbrella organisation called the Academy of
Medical Colleges (1 Wimpole Street, London royal college of psychiatrists, 17 Belgrave
W1M 8AE [020 7290 3913]). The academy Square, London SW1X 8PG (020 7235 2351,
protects and preserves health and the relief of website: www.rcpsych.ac.uk, e-mail:
sickness by supporting, promoting and [email protected]).
coordinating the work of the medical royal col-
leges, offering a forum for discussion and royal college of radiologists, 38 Portland
collaboration. Place, London W1N 3DG (020 7636 4432,
website: www.rcr.ac.uk/enquiries, e-mail:
academy of medical colleges (see above). [email protected]).

royal college of anaesthetists, 4849 royal college of surgeons of edinburgh,

Russell Square, London WC1B 4JP (020 7813 18 Nicolson Street, Edinburgh EH8 9DW
1900, website: www.rcoa.ac.uk). (0131 556 6206, website: www.rcsed.ac.uk, e-
mail: [email protected]).
royal college of general practitioners,
14 Princes Gate, London SW7 1PU (020 7581
royal college of surgeons of england,
3232, website: www.rcgp.org.uk, e-mail:
3543 Lincolns Inn Fields, London WC2A
[email protected]).
3PN (020 7405 3474, website:
royal college of obstetricians and gynae- www.rcseng.ac.uk).
cologists, 27 Sussex Place, Regents Park,
London NW1 4RG (020 7772 6200, website: royal college of surgeons of ireland, 123
www.rcog.org.uk, e-mail: coll.sec@ St Stephens Green, Dublin 2 (00353 1
rcog.org.uk). 4022100, website: www.rcsi.ie).

royal college of ophthalmologists, 17 faculty of occupational medicine, 6 St

Cornwall Terrace, London NW1 4QW (020 Andrews Place, Regents Park, London NW1
7935 0702, website: www.rcopth.ac.uk). 4LE (020 7487 3414).
 Appendix 8: Professional Organisations 811

faculty of pharmaceutical medicine, 1 St medical womens federation, Tavistock

Andrews Place, Regents Park, London NW1 House North, Tavistock Square, London
4LB (020 7224 0343, website: www.fpm. WC1H 9HX (020 7387 7765). The federation
org.uk, e-mail: [email protected]). promotes equal opportunities for women doc-
tors and patients through a network of local
faculty of public health medicine, 4 St associations in the UK. Membership is open to
Andrews Place, London NW1 4LB (020 7935 women doctors and medical students, and the
0243, website: www.fester.his.path.cam. ac.uk/ federation organises local and national seminars
health/fphm.htm, e-mail: enquiries@fphm. and conferences.
ac.uk).
nhs confederation, 1 Warwick Row, Lon-
don SW1E 5ER (020 7959 7272, website:
Voluntary organisations BRITISH MED- www.nhsconfed.net). The NHS Confederation
ICAL ASSOCIATION, BMA House, Tavistock is a representative organisation with more than
Square, London WC1H 9JP (020 7387 4499, 500 trusts, health authorities and health boards
website: www.bma.org.uk). The BMA is a vol- as members.
untary professional association of doctors from
all branches of medicine, with more than 80 per royal college of midwives, 15 Mansfield
cent of practising doctors in the UK in mem- Street, London W1M 0BE (020 7872 5100,
bership. It is a scientific and educational body, website: www.rcm.org.uk). A professional
an independent trade union and a publishing organisation, educational trust and trade union
house. for midwives.

british dental association, 64 Wimpole royal college of nursing of the united

Street, London W1M 8AL (020 7935 0875, kingdom (rcn), 20 Cavendish Square, Lon-
website: www.bda-dentistry.org.uk, e-mail: don W1M 9AE (020 7409 3333, website:
[email protected]). A voluntary www.rcn.org.uk). The RCN is the voluntary
professional body representing the dental pro- professional association for registered, student
fession; it also has scientific and educational and pupil nurses, midwives and health visitors.
responsibilities. It has a worldwide membership of over
300,000. The college promotes the science and
chartered society of physiotherapy, 14 art of nursing, the training of nurses and the
Bedford Row, London WC1R 4ED (020 7306 professional standing and interests of members
6666, fax: 020 7306 6611, website: and the profession. It represents nurses and
www.csp.org.uk, e-mail: [email protected]). negotiates on their behalf with the government
The professional and educational body and and other employers.
trade union for chartered physiotherapists.
royal college of speech and language
therapists, 2 White Hart Yard, London SE1
college of health-care chaplains, Regis- 1NX (020 7378 1200, fax: 020 7403 7254,
trar: Mr C. Webber, 49 Chesterton Park, website: www.rcslt.org, e-mail: postmaster-
Cirencester, Gloucestershire GL7 1XS (01285 @rcslt.org). Responsible for the accreditation of
643660, e-mail: [email protected]). Provides edu- courses and examinations leading to qualifica-
cational opportunities for health-care chaplains, tion to practise as a speech and language therap-
sets and maintains high standards of chaplaincy ist and the maintenance of a register.
and provides support through a regional branch
structure. royal pharmaceutical society of great
britain, 1 Lambeth High Street, London SE1
the college of optometrists, 42 Craven 7JN (020 7735 9141, website: www.rpsgb.
Street, London WC2N 5NG (020 7839 6000, org.uk). A professional body, promoting
website: www.college-optometrists.org, e-mail: pharmaceutical education and science and the
[email protected]). Mem- interests of its members.
bers of the college have passed its qualifying
examination and met its training requirements. royal society of medicine (rsm), 1 Wim-
The colleges aims are to improve and conserve pole Street, London W1M 8AE (020 7290
human vision, to study and research ophthal- 2900, website: www.rsm.ac.uk). An independ-
mic optics and to maintain high professional ent, apolitical society of mainly medical mem-
standards and competence. bers which provides a neutral forum for the
812 Appendix 8: Professional Organisations

exchange of views on medical, educational and advice on medicolegal and professional prob-
other health-care issues. It also provides con- lems associated with clinical practice.
tinuing medical education and possesses one of
the most comprehensive medical libraries in the medical defence union, 230 Blackfriars
world. Road, SE1 8PJ (020 7202 1500, fax: 020 7202
1666, website: www.the-mdu.com, e-mail:
the society of chiropodists and podi- [email protected]).
atrists, 1 Fellmongers Path, Tower Bridge
Road, London SE1 3LY (020 7234 8620, fax: medical protection society, 33 Cavendish
929 7234 8621, website: www.feetforlife.org, e- Square, London W1G 0PS (020 7399 1300,
mail: [email protected]). 020 7399 1301, website: www.mps.org.uk, e-
mail: [email protected]).
Medical defence bodies The three
commercial institutions listed below assist doc- medical and dental defence union of
tors, dentists and other health-care profes- scotland, Mackintosh House, 120 Blyth-
sionals with complaints and negligence claims wood Street, Glasgow G2 4EA (0141 221
arising from clinical practice and payments of 5858, fax: 0141 228 1208, website:
legal costs and damages. They also provide www.mddus.com).
APPENDIX 9: HEALTH-POLICY RESEARCH ORGANISATIONS

This is a list of some of the bodies involved in ing and discussion documents and conducting
health-policy research and consultancy; it is not original research. The documents it produces
exhaustive but includes those bodies that pub- are not BMA policy as such, and are intended
lish regularly for a national audience. to provoke debate inside and outside the associ-
ation. Some work is commissioned internally;
centre for health economics, University otherwise it is free to determine the topics it
of York, Heslington, York YO10 5DD (01904 studies.
321401, website: www.york.ac.uk/inst/che).
Director: Professor Michael Drummond. The health services management centre, Uni-
centre specialises in health-economics research. versity of Birmingham, Park House, 40 Edgbas-
Principal areas of research activity include eco- ton Road, Birmingham, B15 2RT (0121 414
nomic evaluation of health technologies, out- 7050, website: www.hmsc.bham.ac.uk). The
come measurement, primary care, community aim of the centre is to strengthen the manage-
care, and the determinants of health. ment of health services and so promote better
health. Current areas of activity include
centre for health services research, Uni- primary-care provision and management; qual-
versity of Newcastle upon Tyne, 21 Claremont ity management and clinical effectiveness; pri-
Place, Newcastle upon Tyne NE2 4AA (0191 ority setting and rationing, involving users and
222 7045). A multidisciplinary organisation the public in health-service decision making.
that mainly does research aimed at improving The centre conducts research, postgraduate
the health status of people in Europe, the programmes, courses and seminars and under-
United Kingdom and North-East England. takes consultancy.
Among its research interests are health-
technology assessment and effective practice institute for public policy research, 30
and organisation of care. 32 Southampton Street, London WC2E
7RA (020 7470 6100, website: www.ip-
centre for policy on ageing, 25/31 Iron- pr.org.uk). Independent charity whose purpose
monger Row, London EC1V 3QP (020 7553 is to contribute to public understanding of
6500). Director: Dr Gillian Dalley. Using social, economic and political questions
research and analysis, this organisation aims to through research, discussion and publications.
formulate better policies for older people. Established to provide an alternative to the
free-market think tanks.
health economics research unit, Uni-
versity of Aberdeen, Polworth Building, Forest- kings fund, 1113 Cavendish Square, Lon-
erhill, Aberdeen AB25 2ZD (01224 553480, don W1G 0AN (020 7307 2400, website:
website: www.abdn.ac.uk/heru). The unit www.kingsfund.org.uk). Chief executive: Niall
receives core funding from the Chief Scientists Dickson. Independent charity, the original aim
Office of the Scottish Office Departments of of which was to improve the health and health
Health and from competitive research grants care of Londoners. It now carries out research
and funding. It has two underlying aims: to and development, audit and education across
develop methods within health economics; and the UK. Undertakes health-policy research and
to encourage use of the techniques of economic analysis, promotes good practice in health and
appraisal by clinicians and managers in the social care, supports leadership development
NHS. Produces regular discussion papers and offers grants to London projects. Also runs
and undertakes consultancy in the NHS in Kings Fund organisational audit for hospitals.
Scotland. Comprehensive health-policy library open to
researchers.
health policy and economic research
unit, British Medical Association, BMA lse health, London School of Economics
House, Tavistock Square, London WC1H 9JP and Political Science, Houghton Street,
(020 7387 4499, e-mail: [email protected]). London WC2A 2AE (020 7955 6840, web-
Director: Jon Ford. Established in January 1994 site: www.lse.ac.uk/collections/LSEHealthand
to help the BMA make contribution to wider SocialCare). Co-directors: Professor Elias
debates about health policy by producing brief- Mossialos and Professor Martin Knapp.
814 Appendix 9: Health-Policy Research Organisations

Multidisciplinary research centre which brings Owen, CB. Describes itself as an independent
together members of LSE academic staff from observer of the UK health scene and the NHS.
different departments working on health-policy Main areas of activity are invited meetings,
issues. Its fundamental mission is to undertake workshops and seminars, publications, a grant
research consultancy and training in the area of programme and fellowships. Activities currently
international health policy and to influence include an investigation of policy futures for
thereby international health policies. UK health and work on globalisation and
devolution.
national primary care research and devel-
opment centre, University of Manchester, office of health economics, 12 Whitehall,
Williamson Building, Oxford Road, Man- London SW1A 2DY (020 7930 9203, website:
chester M13 9PL (0161 275 7601, website: www.ohe.org). Director: Adrian Towse. Sup-
www.npcrdc.man.ac.uk). Multidisciplinary cen- ported from an annual grant from the Associ-
tre which brings together academic disciplines, ation of the British Pharmaceutical Industry. Its
clinical professions and health-service managers terms of reference are to commission and
to engage in a broad programme of policy- undertake research on the economics of health
relevant research and to promote research-based and health care; to collect and analyse health
service development in primary care. and health-care data from the UK and other
countries; and to disseminate the results of this
work and stimulate discussion of them and
nuffield institute for health, University their policy implications. Publishes on a regular
of Leeds, 7175 Clarendon Road, Leeds LS2 basis a comprehensive compendium of UK
9PL (0113 343 6633, website: www.nuffield. health statistics.
leeds.ac.uk). Interests include health and social
policy and management practice, public health, policy studies institute, 100 Park Village
health services, research and community-care East, London NW1 3SR (020 7468 0468,
research with particular attention to needs website: www.psi.org.uk). Director: Malcolm
assessment and health and social-care out- Rigg. Independent research organisation
comes. Offers courses and undertakes research undertaking studies of social and economic
and consultancy. policy. A registered charity and, since January
1998, a wholly owned subsidiary company of
nuffield trust, 59 New Cavendish Street, the University of Westminster. Among areas of
London W1G 7LP (020 7631 8450, website: interest in health-related research are doctors
www.nuffieldtrust.org.uk). Secretary: John Wyn careers.